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Graydon EK, Malloy AM, Machmach K, Sun P, Paquin-Proulx D, Lizewski S, Lizewski R, Weir DL, Goforth CW, Anderson SK, Letizia AG, Mitre E. High baseline frequencies of natural killer cells are associated with asymptomatic SARS-CoV-2 infection. Curr Res Immunol 2023; 4:100064. [PMID: 37645658 PMCID: PMC10461189 DOI: 10.1016/j.crimmu.2023.100064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/26/2023] [Accepted: 06/03/2023] [Indexed: 08/31/2023] Open
Abstract
This study tested the hypothesis that high frequencies of natural killer (NK) cells are protective against symptomatic SARS-CoV-2 infection. Samples were utilized from the COVID-19 Health Action Response for Marines study, a prospective, observational study of SARS-CoV-2 infection in which participants were enrolled prior to infection and then serially monitored for development of symptomatic or asymptomatic infection. Frequencies and phenotypes of NK cells (CD3-CD14-CD19-CD56+) were assessed by flow cytometry. Individuals that developed asymptomatic infections were found to have higher pre-infection frequencies of total NK cells compared to symptomatic individuals (10.61% [SD 4.5] vs 8.33% [SD 4.6], p = 0.011). Circulating total NK cells decreased over the course of infection, reaching a nadir at 4 weeks, while immature NK cells increased, a finding confirmed by multidimensional reduction analysis. These results indicate that NK cells likely play a key role in controlling the severity of clinical illness in individuals infected with SARS-CoV-2.
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Affiliation(s)
- Elizabeth K. Graydon
- Department of Microbiology and Immunology, Uniformed Services University, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | | | - Kawthar Machmach
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring MD, USA
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Peifang Sun
- Infectious Disease Directorate, Naval Medical Research Center, Silver Spring, MD, USA
| | - Dominic Paquin-Proulx
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
- Emerging Infectious Diseases Branch, Walter Reed Army Institute of Research, Silver Spring MD, USA
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | | | | | - Dawn L. Weir
- Infectious Disease Directorate, Naval Medical Research Center, Silver Spring, MD, USA
| | - Carl W. Goforth
- Infectious Disease Directorate, Naval Medical Research Center, Silver Spring, MD, USA
| | - Stephen K. Anderson
- Basic Science Program, Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Andrew G. Letizia
- Infectious Disease Directorate, Naval Medical Research Center, Silver Spring, MD, USA
| | - Edward Mitre
- Department of Microbiology and Immunology, Uniformed Services University, Bethesda, MD, USA
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Santri IN, Wardani Y, Phiri YVA, Nyam G, Putri TA, Isni K, Suryani D, Sambo G. Associations Between Indoor Air Pollutants and Risk Factors for Acute Respiratory Infection Symptoms in Children Under 5: An Analysis of Data From the Indonesia Demographic Health Survey. J Prev Med Public Health 2023; 56:255-263. [PMID: 37287203 DOI: 10.3961/jpmph.22.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/06/2023] [Indexed: 06/09/2023] Open
Abstract
OBJECTIVES The study investigated the association between indoor air pollution (IAP) and risk factors for acute respiratory infection (ARI) symptoms in children under 5 years of age. METHODS A cross-sectional study was conducted using data derived from Indonesia Demographic and Health Survey in 2017. Binary logistic regression modeling was employed to examine each predictor variable associated with ARI among children under 5 years of age in Indonesia. RESULTS The study included a total of 4936 households with children. Among children under 5 years old, 7.2% reported ARI symptoms. The presence of ARI symptoms was significantly associated with the type of residence, wealth index, and father's smoking frequency, which were considered the sample's socio-demographic characteristics. In the final model, living in rural areas, having a high wealth index, the father's smoking frequency, and a low education level were all linked to ARI symptoms. CONCLUSIONS The results revealed that households in rural areas had a substantially higher level of reported ARI symptoms among children under 5 years old. Furthermore, the father's smoking frequency and low education level were associated with ARI symptoms.
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Affiliation(s)
| | - Yuniar Wardani
- Faculty of Public Health, Universitas of Ahmad Dahlan, Yogyakarta, Indonesia
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Yohane Vincent Abero Phiri
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Institute for Health Research and Communication (IHRC), Lilongwe, Malawi
| | - Gunchmaa Nyam
- Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Tyas Aisyah Putri
- Faculty of Public Health, Universitas of Ahmad Dahlan, Yogyakarta, Indonesia
| | - Khoiriyah Isni
- Faculty of Public Health, Universitas of Ahmad Dahlan, Yogyakarta, Indonesia
| | - Dyah Suryani
- Faculty of Public Health, Universitas of Ahmad Dahlan, Yogyakarta, Indonesia
| | - Grace Sambo
- School of Public Health, Tzu Chi University, Hualien, Taiwan
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Mosegui GB, Antoñanzas F, de Mello Vianna CM. Cost of lost productivity from acute respiratory infections in South America. Rev Panam Salud Publica 2023; 47:e65. [PMID: 37066128 PMCID: PMC10101008 DOI: 10.26633/rpsp.2023.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 04/18/2023] Open
Abstract
Objectives To estimate the burden of permanent productivity losses caused by acute respiratory infections in South American countries in 2019. Methods Mortality data from the Global Burden of Disease Study 2019 were analyzed to estimate the burden of disease attributable to acute respiratory infections. An approach based on the human capital method was used to estimate the cost of permanent productivity losses associated with respiratory diseases. To calculate this cost, the sum of the years of productive life lost for each death was multiplied by the proportion in the workforce and the employment rate, and then by the annual minimum wage or purchasing power parity in United States dollars (US$) for each country in the economically active age groups. Separate calculations were done for men and women. Results The total number of deaths from acute respiratory infections in 2019 was 30 684 and the years of productive life lost were 465 211 years. The total cost of permanent productivity loss was about US$ 835 million based on annual minimum wage and US$ 2 billion in purchasing power parity, representing 0.024% of the region's gross domestic product. The cost per death was US$ 33 226. The cost of productivity losses differed substantially between countries and by sex. Conclusion Acute respiratory infections impose a significant economic burden on South America in terms of health and productivity. Characterization of the economic costs of these infections can support governments in the allocation of resources to develop policies and interventions to reduce the burden of acute respiratory infections.
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Affiliation(s)
- Gabriela B.G. Mosegui
- Fluminense Federal UniversityNiteróiRio de JaneiroBrazilFluminense Federal University, Niterói, Rio de Janeiro, Brazil.
- Gabriela B.G. Mosegui,
| | - Fernando Antoñanzas
- University of La RiojaLogroñoLa RiojaSpainUniversity of La Rioja, Logroño, La Rioja, Spain.
| | - Cid M. de Mello Vianna
- Rio de Janeiro State UniversityRio de JaneiroBrazilRio de Janeiro State University, Rio de Janeiro, Brazil.
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Hagiwara Y, Harada K, Nealon J, Okumura Y, Kimura T, Chaves SS. Seasonal influenza, its complications and related healthcare resource utilization among people 60 years and older: A descriptive retrospective study in Japan. PLoS One 2022; 17:e0272795. [PMID: 36191012 PMCID: PMC9529100 DOI: 10.1371/journal.pone.0272795] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 07/26/2022] [Indexed: 11/06/2022] Open
Abstract
Evidence suggests that older people aged ≥65 years and those aged 60–64 years with chronic medical conditions are at higher risk of developing severe complications due to influenza virus infection when compared with young, healthy adults. Although seasonal influenza is monitored through a nationwide passive surveillance in Japan, influenza related outcomes and medical resource consumption have not been fully documented. This retrospective database study aimed to describe the epidemiological and clinical characteristics of medically attended influenza cases aged ≥60 years and the associated medical resource consumption in Japan. We used clinically diagnosed influenza (CDI) based on the international classification of disease codes, and laboratory-confirmed influenza (LCI) based on influenza test results, to identify the patient population during a total of nine seasons (2010/2011 to 2018/2019). A total of 372,356 CDI and 31,122 LCI cases were identified from 77 medical institutions. The highest numbers of medically-attended influenza episodes were in patients aged 65–74 years and 75–84 years. On average, across seasons, 5.9% of all-cause hospitalizations were attributable to CDI and 0.4% were LCI. Influenza viruses type A and B co-circulated annually in varying degree of intensity and were associated with similar level of complications, including cardiovascular-related. Oxygen therapy increased with age; by contrast, mechanical ventilation, dialysis, blood transfusion, and intensive care unit admission were higher in the younger groups. In-hospital mortality for inpatients aged ≥ 85 years with CDI and LCI were 18.6% and 15.5%, respectively. Considering the burden associated with medically-attended influenza in this population, influenza prevention, laboratory confirmation and clinical management should be emphasized by general practicians and specialists like cardiologists to protect this aging population.
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Affiliation(s)
- Yuriko Hagiwara
- Medical Evidence Generation, Medical Affairs, Sanofi, Tokyo, Japan
- Department of Health Economics and Outcomes Research, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Kazumasa Harada
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Joshua Nealon
- Medical Evidence Generation, Medical Affairs, Sanofi, Lyon, France
- Li Ka Shing Faculty of Medicine, World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, The University of Hong Kong, Hong Kong Special Administrative Region, China
- * E-mail:
| | - Yasuyuki Okumura
- Research and Analytics Department, Real World Data, Co., Ltd., Kyoto, Japan
- The Initiative for Clinical Epidemiological Research, Tokyo, Japan
| | - Takeshi Kimura
- Research and Analytics Department, Real World Data, Co., Ltd., Kyoto, Japan
| | - Sandra S. Chaves
- Department of Modelling, Epidemiology and Data Science, Sanofi Pasteur, Lyon, France
- Foundation for Influenza Epidemiology, Fondation de France, Paris, France
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Suryadevara M, Fajardo FP, Aponte CC, Carrillo Aponte JL, Prado EO, Hidalgo I, Bonville CA, Torres I, Domachowske JB. Etiologies of outpatient medically attended acute respiratory infections among young Ecuadorian children prior to the start of the 2020 SARS-CoV-2 pandemic. Influenza Other Respir Viruses 2022; 17:e13056. [PMID: 36172889 PMCID: PMC9537809 DOI: 10.1111/irv.13056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/04/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Implementation of respiratory virus prevention measures requires detailed understanding of regional epidemiology; however, data from many tropical countries are sparse. We describe etiologies of ambulatory pediatric acute respiratory tract infections (ARTI) in Ecuador immediately preceding the onset of the SARS-CoV-2 pandemic. METHODS Children < 5 years presenting to a designated study site with an ARTI were eligible. Informed consent was obtained. Demographic and clinical data were recorded. A nasopharyngeal swab was collected, processed, and analyzed using multiplex polymerase chain reaction (PCR) for common respiratory pathogens. Rhinovirus/enterovirus positive samples were further characterized by genomic sequencing. RESULTS A total of 820 subjects were enrolled in the study between July 2018 and March 2020. A total of 655 (80%) samples identified at least one pathogen. Rhinoviruses (44%) were most common, followed by enteroviruses (17%), parainfluenza viruses (17%), respiratory syncytial virus (RSV) (15%), and influenza viruses (13%). Enterovirus D68 was the most common enterovirus detected and was among the leading causes of bronchiolitis. Seasonal RSV and influenza virus activity were different along the coast compared with the highlands. CONCLUSIONS Ongoing regional surveillance studies are necessary to optimize available and emerging pathogen-specific preventative measures.
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Affiliation(s)
- Manika Suryadevara
- Department of PediatricsSUNY Upstate Medical UniversitySyracuseNew YorkUSA
| | | | - Cinthya Cueva Aponte
- Research Center at Hospital Teófilo DávilaSUNY Upstate Medical UniversityMachalaEcuador
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Fathmawati F, Rauf S, Indraswari BW. Factors related with the incidence of acute respiratory infections in toddlers in Sleman, Yogyakarta, Indonesia: Evidence from the Sleman Health and Demographic Surveillance System. PLoS One 2021; 16:e0257881. [PMID: 34559864 PMCID: PMC8462707 DOI: 10.1371/journal.pone.0257881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 09/14/2021] [Indexed: 12/04/2022] Open
Abstract
Various factors associated with Acute Respiratory Infections (ARI) in toddlers have been widely observed, but there are no studies using data from the Sleman Health and Demographic Surveillance System (HDSS). This study aimed to determine the factors associated with ARI in children under five in Sleman, Yogyakarta, Indonesia. This research was an observational analytic study with a cross-sectional design, using secondary data from the Sleman HDSS. Data of 463 children under five who met the inclusion and exclusion criteria were used in this study. Inclusion criteria were toddlers who have complete observed variable data. The variables observed were the characteristics of children under five, the attributes of the mother, the physical condition of the house, the use of mosquito coils, sanitation facilities, and sources of drinking water. The exclusion criteria were toddlers with pulmonary tuberculosis in the past year. Data analysis used chi-squared tests for bivariate analysis and multivariate logistic regression analysis. The results showed that working mothers had a greater risk of ARI under five children with OR 1.46 (95% CI = 1.01–2.11), and groundwater as a water source was a protective factor against the occurrence of ARI in toddlers with OR 0.46 (95% CI = 0.26–0.81). After a logistic regression analysis was performed, only the drinking water source variable had a statistically significant relationship with the incidence of ARI in children under five with OR = 0.47 (95% CI = 0.268–0.827). Research on the relationship between water quality and the incidence of ARI in children under five is needed to follow up on these findings.
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Affiliation(s)
- Fathmawati Fathmawati
- Department of Environmental Health, Politeknik Kesehatan Kemenkes Pontianak, Pontianak, Indonesia
- * E-mail: ,
| | - Saidah Rauf
- Masohi Nursing Study Program, Politeknik Kesehatan Kemenkes Maluku, Ambon, Indonesia
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Azziz-Baumgartner E, Bruno A, Daugherty M, Chico ME, Lopez A, Arriola CS, de Mora D, Ropero AM, Davis WW, McMorrow M, Cooper PJ. Incidence and seasonality of respiratory viruses among medically attended children with acute respiratory infections in an Ecuador birth cohort, 2011-2014. Influenza Other Respir Viruses 2021; 16:24-33. [PMID: 34432362 PMCID: PMC8692806 DOI: 10.1111/irv.12887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/21/2021] [Accepted: 06/24/2021] [Indexed: 01/04/2023] Open
Abstract
Background Ecuador annually has handwashing and respiratory hygiene campaigns and seasonal influenza vaccination to prevent respiratory virus illnesses but has yet to quantify disease burden and determine epidemic timing. Methods To identify respiratory virus burden and assess months with epidemic activity, we followed a birth cohort in northwest Ecuador during 2011–2014. Mothers brought children to the study clinic for routine checkups at ages 1, 2, 3, 5, and 8 years or if children experienced any acute respiratory illness symptoms (e.g., cough, fever, or difficulty breathing); clinical care was provided free of charge. Those with medically attended acute respiratory infections (MAARIs) were tested for common respiratory viruses via real‐time reverse‐transcription polymerase chain reaction (rRT‐PCR). Results In 2011, 2376 children aged 1–4 years (median 35 months) were enrolled in the respiratory cohort and monitored for 7017.5 child‐years (cy). The incidence of respiratory syncytial virus (RSV) was 23.9 (95% CI 17.3–30.5), influenza 10.6 (2.4–18.8), adenoviruses 6.7 (4.6–28.0), parainfluenzas 5.0 (2.3–10.5), and rhinoviruses, bocaviruses, human metapneumoviruses, seasonal coronaviruses, and enteroviruses <3/100 cy among children aged 12–23 months and declined with age. Most (75%) influenza detections occurred April–September. Conclusion Cohort children frequently had MAARIs, and while the incidence decreased rapidly among older children, more than one in five children aged 12–23 months tested positive for RSV, and one in 10 tested positive for influenza. Our findings suggest this substantial burden of influenza occurred more commonly during the winter Southern Hemisphere influenza season.
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Affiliation(s)
- Eduardo Azziz-Baumgartner
- International Epidemiology and Research Team, Influenza Division, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alfredo Bruno
- Faculty of Veterinary Medicine and Zootechnics, Universidad Agraria del Ecuador, Guayaquil, Ecuador.,National Reference Laboratory for Influenza and Other Respiratory Viruses, Instituto Nacional de Investigación en Salud Pública (INSPI), Guayaquil, Ecuador
| | - Michael Daugherty
- International Epidemiology and Research Team, Influenza Division, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Martha E Chico
- Fundación Ecuatoriana Para Investigación en Salud, Quinindé, Ecuador
| | - Andrea Lopez
- School of Medicine, Universidad Internacional del Ecuador, Quito, Ecuador
| | - Carmen Sofia Arriola
- International Epidemiology and Research Team, Influenza Division, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Domenica de Mora
- International Epidemiology and Research Team, Influenza Division, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alba María Ropero
- Immunizations Program, Pan American Health Organization, Washington, DC, USA
| | - William W Davis
- International Epidemiology and Research Team, Influenza Division, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Meredith McMorrow
- Enhanced Surveillance Platforms Team, Division of Viral Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Philip J Cooper
- School of Medicine, Universidad Internacional del Ecuador, Quito, Ecuador.,Institute of Infection and Immunity, St George's University of London, London, UK
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COŞKUN S, KIRKIL C, KİRKİL G. The change in the frequency of community acquired acute respiratory tract infections in weight loss period after bariatric surgery: An observational case-crossover study. Are those who have had bariatric surgery at risk? Archives of Clinical and Experimental Medicine 2021. [DOI: 10.25000/acem.938844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Sabin LL, Estrella B, Sempértegui F, Farquhar N, Mesic A, Halim N, Lin CY, Rodriguez O, Hamer DH. Household Costs Associated with Hospitalization of Children with Severe Pneumonia in Quito, Ecuador. Am J Trop Med Hyg 2020; 102:731-739. [PMID: 32067631 DOI: 10.4269/ajtmh.19-0721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Pneumonia remains a leading cause of morbidity and mortality in young children. The total cost of pneumonia-related hospitalization, including household-level cost, is poorly understood. To better understand this burden in an urban setting in South America, we incorporated a cost study into a trial assessing zinc supplements in treatment of severe pneumonia among children aged 2-59 months at a public hospital in Quito, Ecuador, which provides such treatment at no charge. Data were collected from children's caregivers at hospitalization and discharge on out-of-pocket payments for medical and nonmedical items, and on employment and lost work time. Analyses encompassed three categories: direct medical costs, direct nonmedical costs, and indirect costs, which covered foregone wages (from caregivers' self-reported lost earnings) and opportunity cost of caregivers' lost time (based on the unskilled labor wage in Ecuador). Caregivers of 153 children completed all questionnaires. Overall, 57% of children were aged less than 12 months, and 46% were female. Just over 50% of mothers and fathers had completed middle school. Most reported direct costs, which averaged $33. Most also reported indirect costs, the mean of which was $74. Fifty-seven reported lost earnings (mean = $79); 29 reported lost time (estimated mean cost = $37). Stratified analyses revealed similar costs for children < 12 months and ≥ 12 months, with variations for specific items. Costs for hospital-based treatment of severe pneumonia in young children represent a major burden for households in low- to middle-income settings, even when such treatment is intended to be provided at no cost.
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Affiliation(s)
- Lora L Sabin
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Bertha Estrella
- Escuela de Medicina, Universidad Central del Ecuador, Quito, Ecuador.,Corporacion Ecuatoriana de Biotecnologia, Quito, Ecuador
| | - Fernando Sempértegui
- Escuela de Medicina, Universidad Central del Ecuador, Quito, Ecuador.,Corporacion Ecuatoriana de Biotecnologia, Quito, Ecuador
| | - Norman Farquhar
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, Michigan
| | - Aldina Mesic
- Innovations for Poverty Action Zambia, Lusaka, Zambia
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Chia-Ying Lin
- United States Agency for International Development, Arlington, Virginia
| | | | - Davidson H Hamer
- Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
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