Community Case Management of Fever Due to Malaria and Pneumonia in Children Under Five in Zambia: A Cluster Randomized Controlled Trial

Background

Pneumonia and malaria, two of the leading causes of morbidity and mortality among children under five in Zambia, often have overlapping clinical manifestations. Zambia is piloting the use of artemether-lumefantrine (AL) by community health workers (CHWs) to treat uncomplicated malaria. Valid concerns about potential overuse of AL could be addressed by the use of malaria rapid diagnostics employed at the community level. Currently, CHWs in Zambia evaluate and treat children with suspected malaria in rural areas, but they refer children with suspected pneumonia to the nearest health facility. This study was designed to assess the effectiveness and feasibility of using CHWs to manage nonsevere pneumonia and uncomplicated malaria with the aid of rapid diagnostic tests (RDTs).

Methods and Findings

Community health posts staffed by CHWs were matched and randomly allocated to intervention and control arms. Children between the ages of 6 months and 5 years were managed according to the study protocol, as follows. Intervention CHWs performed RDTs, treated test-positive children with AL, and treated those with nonsevere pneumonia (increased respiratory rate) with amoxicillin. Control CHWs did not perform RDTs, treated all febrile children with AL, and referred those with signs of pneumonia to the health facility, as per Ministry of Health policy. The primary outcomes were the use of AL in children with fever and early and appropriate treatment with antibiotics for nonsevere pneumonia. A total of 3,125 children with fever and/or difficult/fast breathing were managed over a 12-month period. In the intervention arm, 27.5% (265/963) of children with fever received AL compared to 99.1% (2066/2084) of control children (risk ratio 0.23, 95% confidence interval 0.14–0.38). For children classified with nonsevere pneumonia, 68.2% (247/362) in the intervention arm and 13.3% (22/203) in the control arm received early and appropriate treatment (risk ratio 5.32, 95% confidence interval 2.19–8.94). There were two deaths in the intervention and one in the control arm.

Conclusions

The potential for CHWs to use RDTs, AL, and amoxicillin to manage both malaria and pneumonia at the community level is promising and might reduce overuse of AL, as well as provide early and appropriate treatment to children with nonsevere pneumonia.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00513500","term_id":"NCT00513500"}}NCT00513500 Please see later in the article for the Editors'' Summary     

Perceived Quality of Care for Common Childhood Illnesses: Facility versus Community Based Providers in Uganda

Objective

To compare caretakers’ perceived quality of care (PQC) for under-fives treated for malaria, pneumonia and diarrhoea by community health workers (CHWs) and primary health facility workers (PHFWs).

Methods

Caretaker rated PQC for children aged (2-59) months treated by either CHWs or PHFWs for a bought of malaria, pneumonia or diarrhoea was cross-sectionally compared in quality domains of accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment and trust. Child samples were randomly drawn from CHW (419) and clinic (399) records from eight Midwestern Uganda districts. An overall PQC score was predicted through factor analysis. PQC scores were compared for CHWs and PHFWs using Wilcoxon rank-sum test. Multinomial logistic regression models were used to specify the association between categorized PQC and service providers for each quality domain. Finally, overall PQC was dichotomized into “high” and “low” based on median score and relative risks (RR) for PQC-service provider association were modeled in a “modified” Poisson regression model.

Results

Mean (SD) overall PQC was significantly higher for CHWs 0.58 (0 .66) compared to PHFWs -0.58 (0.94), p<0.0001. In “modified” Poisson regression, the proportion of caretakers reporting high PQC was higher for CHWS compared to PHFWs, RR=3.1, 95%CI(2.5-3.8). In multinomial models PQC was significantly higher for CHWs compared to PHFWs in all domains except for continuity.

Conclusion

PQC was significantly higher for CHWs compared to PHFWs in this resource constrained setting. CHWs should be tapped human resources for universal health coverage while scaling up basic child intervention as PQC might improve intervention utilization.     

Revisiting Community Case Management of Childhood Pneumonia: Perceptions of Caregivers and Grass Root Health Providers in Uttar Pradesh and Bihar,Northern India

Background

Community-acquired pneumonia (CAP) is the leading cause of under-five mortality globally with almost one-quarter of deaths occurring in India.

Objectives

To identify predisposing, enabling and service-related factors influencing treatment delay for CAP in rural communities of two states in India. Factors investigated included recognition of danger signs of CAP, health care decision making, self-medication, treatment and referral by local practitioners, and perceptions about quality of care.

Methods

Qualitative research employing case studies (CS) of care-seeking, key informant interviews (KII), semi-structured interviews (SSI) and focus group discussions (FGD) with both video presentations of CAP signs, and case scenarios. Interviews and FGDs were conducted with parents of under-five children who had suffered CAP, community health workers (CHW), and rural medical practitioners (RMP).

Results

From September 2013 to January 2014, 30 CS, 43 KIIs, 42 SSIs, and 42 FGDs were conducted. Recognition of danger signs of CAP among caregivers was poor. Fast breathing, an early sign of CAP, was not commonly recognized. Chest in-drawing was recognized as a sign of serious illness, but not commonly monitored by removing a child’s clothing. Most cases of mild to moderate CAP were brought to RMP, and more severe cases taken to private clinics in towns. Mothers consulted local RMP directly, but decisions to visit doctors outside the village required consultation with husband or mother-in-law. By the time most cases reached a public tertiary-care hospital, children had been ill for a week and treated by 2-3 providers. Quality of care at government facilities was deemed poor by caregivers.

Conclusion

To reduce CAP-associated mortality, recognition of its danger signs and the consequences of treatment delay needed to be better recognized by caregivers, and confidence in government facilities increased. The involvement of RMP in community based CAP programs needs to be investigated further given their widespread popularity.     

Valuing and Sustaining (or Not) the Ability of Volunteer Community Health Workers to Deliver Integrated Community Case Management in Northern Ghana: A Qualitative Study

Background

Within the integrated community case management of childhood illnesses (iCCM) programme, the traditional health promotion and prevention role of community health workers (CHWs) has been expanded to treatment. Understanding both the impact and the implementation experience of this expanded role are important. In evaluating UNICEF’s implementation of iCCM, this qualitative case study explores the implementation experience in Ghana.

Methods and Findings

Data were collected through a rapid appraisal using focus groups and individual interviews during a field visit in May 2013 to Accra and the Northern Region of Ghana. We sought to understand the experience of iCCM from the perspective of locally based UNICEF staff, their partners, researchers, Ghana health services management staff, CHWs and their supervisors, nurses in health facilities and mothers receiving the service. Our analysis of the findings showed that there is an appreciation both by mothers and by facility level staff for the contribution of CHWs. Appreciation was expressed for the localisation of the treatment of childhood illness, thus saving mothers from the effort and expense of having to seek treatment outside of the village. Despite an overall expression of value for the expanded role of CHWs, we also found that there were problems in supporting and sustaining their efforts. The data showed concern around CHWs being unpaid, poorly supervised, regularly out of stock, lacking in essential equipment and remaining outside the formal health system.

Conclusions

Expanding the roles of CHWs is important and can be valuable, but contextual and health system factors threaten the sustainability of iCCM in Ghana. In this and other implementation sites, policymakers and key donors need to take into account historical lessons from the CHW literature, while exploring innovative and sustainable mechanisms to secure the programme as part of a government owned and government led strategy.     

Updated Prevalences of Asthma,Allergy, and Airway Symptoms,and a Systematic Review of Trends over Time for Childhood Asthma in Shanghai,China

Background

The prevalence of asthma among Shanghai children has increased over time. This increase might be associated with changes in environmental exposures. Investigation of the time-trend of asthma and current prevalences is essential to understanding the causes.

Objective

To estimate the current prevalences of asthma, allergies and other respiratory symptoms among Shanghai preschool children, and to investigate the time-trend of childhood asthma prevalence of from 1990 to 2011.

Methods

From April 2011 to April 2012, the CCHH (China, Children, Homes, Health) cross-sectional study was conducted in Shanghai. Questionnaires were distributed to 17,898 parents or guardians of preschool children from 72 kindergartens in 5 districts. Previous similar studies were also summarized by a systematic literature review.

Results

From a total of 14,884 questionnaires for 3–7 year old children, prevalences of the following diseases and symptoms were calculated: asthma 10.2%, wheeze (ever) 28.1%, pneumonia (ever) 33.5%, otitis media 11.0%, rhinitis (ever) 54.1%, hay fever 12.2%, eczema (ever) 22.7%, and food allergy 15.7%. Urban children had higher prevalences of most symptoms than suburban children. The prevalence of asthma has increased significantly, almost five-fold, from 2.1% in 1990 to 10.2% in the present study. The prevalence of asthma in boys was higher than in girls in the present study and in all reviewed studies.

Conclusions

Asthma, allergy and airway symptoms are common among preschool children in Shanghai. The prevalence of childhood asthma in Shanghai has increased rapidly from 1990 to 2011.     

Can Community Health Workers Report Accurately on Births and Deaths? Results of Field Assessments in Ethiopia,Malawi and Mali

Introduction

Most low-income countries lack complete and accurate vital registration systems. As a result, measures of under-five mortality rates rely mostly on household surveys. In collaboration with partners in Ethiopia, Ghana, Malawi, and Mali, we assessed the completeness and accuracy of reporting of births and deaths by community-based health workers, and the accuracy of annualized under-five mortality rate estimates derived from these data. Here we report on results from Ethiopia, Malawi and Mali.

Method

In all three countries, community health workers (CHWs) were trained, equipped and supported to report pregnancies, births and deaths within defined geographic areas over a period of at least fifteen months. In-country institutions collected these data every month. At each study site, we administered a full birth history (FBH) or full pregnancy history (FPH), to women of reproductive age via a census of households in Mali and via household surveys in Ethiopia and Malawi. Using these FBHs/FPHs as a validation data source, we assessed the completeness of the counts of births and deaths and the accuracy of under-five, infant, and neonatal mortality rates from the community-based method against the retrospective FBH/FPH for rolling twelve-month periods. For each method we calculated total cost, average annual cost per 1,000 population, and average cost per vital event reported.

Results

On average, CHWs submitted monthly vital event reports for over 95 percent of catchment areas in Ethiopia and Malawi, and for 100 percent of catchment areas in Mali. The completeness of vital events reporting by CHWs varied: we estimated that 30%-90% of annualized expected births (i.e. the number of births estimated using a FPH) were documented by CHWs and 22%-91% of annualized expected under-five deaths were documented by CHWs. Resulting annualized under-five mortality rates based on the CHW vital events reporting were, on average, under-estimated by 28% in Ethiopia, 32% in Malawi, and 9% in Mali relative to comparable FPHs. Costs per vital event reported ranged from $21 in Malawi to $149 in Mali.

Discussion

Our findings in Mali suggest that CHWs can collect complete and high-quality vital events data useful for monitoring annual changes in under-five mortality rates. Both the supervision of CHWs in Mali and the rigor of the associated field-based data quality checks were of a high standard, and the size of the pilot area in Mali was small (comprising of approximately 53,205 residents in 4,200 households). Hence, there are remaining questions about whether this level of vital events reporting completeness and data quality could be maintained if the approach was implemented at scale. Our experience in Malawi and Ethiopia suggests that, in some settings, establishing and maintaining the completeness and quality of vital events reporting by CHWs over time is challenging. In this sense, our evaluation in Mali falls closer to that of an efficacy study, whereas our evaluations in Ethiopia and Malawi are more akin to an effectiveness study. Our overall findings suggest that no one-size-fits-all approach will be successful in guaranteeing complete and accurate reporting of vital events by CHWs.     

Building Social Networks for Maternal and Newborn Health in Poor Urban Settlements: A Cross-Sectional Study in Bangladesh

Background

The beneficial influence of social networks on health and wellbeing is well-established. In poor urban settlements in Bangladesh, BRAC’s Manoshi programme trains community health workers (CHWs) to support women through pregnancy, delivery and postpartum periods. This paper test the hypothesis that the introduction of CHWs as weak ties into the social networks of Manoshi members mediates improvements in maternal and neonatal health (MNH) best practices by providing support, facilitating ideational change, connecting mother to resources, and strengthening or countering the influence of strong ties.

Methods

1000 women who had given birth in the last three months were identified and interviewed as part of ongoing monitoring of 5 poor urban settlements in Dhaka, Bangladesh. A social networks questionnaire was administered which elicited women’s perceived networks around pregnancy, delivery and post-partum periods. Mediation analysis was performed to test the hypothesis that penetration of Manoshi CHWs into women’s perceived networks has a beneficial effect on MNH best practises.

Results

The presence and influence of Manoshi CHWs in women’s networks significantly mediated the effect of Manoshi membership on MNH best practices. Respondents who were Manoshi members and who listed Manoshi CHWs as part of their support networks were significantly more likely to deliver with a trained birth attendant (OR 3.61; 95%CI 2.36–5.51), to use postnatal care (OR 3.09; 95%CI 1.83–5.22), and to give colostrum to their newborn (OR 7.51; 95%CI 3.51–16.05).

Conclusion

Manoshi has succeeded in penetrating the perceived pregnancy, delivery and post-partum networks of poor urban women through the introduction of trained CHWs. Study findings demonstrate the benefits of moving beyond urban health care delivery models that concentrate on the provision of clinical services by medical providers, to an approach that nurtures the power of social networks as a means to support the poorest and most marginalized in changing behaviour and effectively accessing appropriate maternal services.     

Predictors of Duration and Treatment Failure of Severe Pneumonia in Hospitalized Young Nepalese Children

Background

Pneumonia in young children is still the most frequent cause of death in developing countries. We aimed to identify predictors for recovery and treatment failure in children hospitalized with severe pneumonia.

Methods

We enrolled 610 Nepalese children, aged 2 – 35 months from February 2006 to June 2008. Study participants were provided with standard treatment for pneumonia and followed up until discharge. Three multiple regression models representing clinical variables, clinical and radiological combined and all variables, including C-reactive protein (CRP) and viral etiology were used to assess the associations.

Results

The median age of study participants was 6 months with 493 (82%) infants and 367 (61%) males. The median time (IQR) till recovery was 49 (31, 87) hours and treatment failure was experienced by 209 (35%) of the children. Younger age, hypoxia on admission and radiographic pneumonia were independent predictors for both prolonged recovery and risk of treatment failure. While wasting and presence of any danger sign also predicted slower recovery, Parainfluenza type 1 isolated from the nasopharynx was associated with earlier resolution of illness. Gender, being breastfed, stunting, high fever, elevated CRP, presence of other viruses and supplementation with oral zinc did not show any significant association with these outcomes.

Conclusion

Age, hypoxia and consolidation on chest radiograph were significant predictors for time till recovery and treatment failure in children with severe pneumonia. While chest radiograph is not always needed, detection and treatment of hypoxia is a crucial step to guide the management of hospitalized children with pneumonia.     

The Burden and Etiology of Community-Onset Pneumonia in the Aging Japanese Population: A Multicenter Prospective Study

Background

The increasing burden of pneumonia in adults is an emerging health issue in the era of global population aging. This study was conducted to elucidate the burden of community-onset pneumonia (COP) and its etiologic fractions in Japan, the world’s most aged society.

Methods

A multicenter prospective surveillance for COP was conducted from September 2011 to January 2013 in Japan. All pneumonia patients aged ≥15 years, including those with community-acquired pneumonia (CAP) and health care-associated pneumonia (HCAP), were enrolled at four community hospitals on four major islands. The COP burden was estimated based on the surveillance data and national statistics.

Results

A total of 1,772 COP episodes out of 932,080 hospital visits were enrolled during the surveillance. The estimated overall incidence rates of adult COP, hospitalization, and in-hospital death were 16.9 (95% confidence interval, 13.6 to 20.9), 5.3 (4.5 to 6.2), and 0.7 (0.6 to 0.8) per 1,000 person-years (PY), respectively. The incidence rates sharply increased with age; the incidence in people aged ≥85 years was 10-fold higher than that in people aged 15-64 years. The estimated annual number of adult COP cases in the entire Japanese population was 1,880,000, and 69.4% were aged ≥65 years. Aspiration-associated pneumonia (630,000) was the leading etiologic category, followed by Streptococcus pneumoniae-associated pneumonia (530,000), Haemophilus influenzae-associated pneumonia (420,000), and respiratory virus-associated pneumonia (420,000), including influenza-associated pneumonia (30,000).

Conclusions

A substantial portion of the COP burden occurs among elderly members of the Japanese adult population. In addition to the introduction of effective vaccines for S. pneumoniae and influenza, multidimensional approaches are needed to reduce the pneumonia burden in an aging society.     

Abolishing Fees at Health Centers in the Context of Community Case Management of Malaria: What Effects on Treatment-Seeking Practices for Febrile Children in Rural Burkina Faso?

Introduction

Burkina Faso started nationwide community case management of malaria (CCMm) in 2010. In 2011, health center user fees for children under five were abolished in some districts.

Objective

To assess the effects of concurrent implementation of CCMm and user fees abolition on treatment-seeking practices for febrile children.

Methods

This is a natural experiment conducted in the districts of Kaya (CCMm plus user fees abolition) and Zorgho (CCMm only). Registry data from 2005 to 2014 on visits for malaria were collected from all eight rural health centers in the study area. Annual household surveys were administered during malaria transmission season in 2011 and 2012 in 1,035 randomly selected rural households. Interrupted time series models were fitted for registry data and Fine and Gray’s competing risks models for survey data.

Results

User fees abolition in Kaya significantly increased health center use by eligible children with malaria (incidence rate ratio for intercept change = 2.1, p <0.001). In 2011, in Kaya, likelihood of health center use for febrile children was three times higher and CHW use three times lower when caregivers knew services were free. Among the 421 children with fever in 2012, the delay before visiting a health center was significantly shorter in Kaya than in Zorgho (1.46 versus 1.79 days, p <0.05). Likelihood of visiting a health center on the first day of fever among households <2.5km or <5 km from a health center was two and three times higher in Kaya than in Zorgho, respectively (p <0.001).

Conclusions

User fees abolition reduced visit delay for febrile children living close to health centers. It also increased demand for and use of health center for children with malaria. Concurrently, demand for CHWs’ services diminished. User fees abolition and CCMm should be coordinated to maximize prompt access to treatment in rural areas.     

Cytokine Concentrations in Plasma from Children with Severe and Non-Severe Community Acquired Pneumonia

Background

Children in low and middle-income countries have a high burden of pneumonia. Measuring the cytokine responses may be useful to identify novel markers for diagnosing, monitoring, and treating pneumonia.

Objective

To describe and compare a wide range of inflammatory mediators in plasma from children with WHO-defined severe and non-severe community acquired pneumonia (CAP), and explore to what extent certain mediators are associated with severity and viral detection.

Methods

We collected blood samples from 430 children with severe (n = 43) and non-severe (n = 387) CAP. Plasma from these children were analysed for 27 different cytokines, and we measured the association with age, disease severity and viral detection.

Results

There were generally higher plasma concentrations of several cytokines with both pro-inflammatory and anti-inflammatory effects among children with severe CAP than in children with non-severe CAP. We found significantly higher concentrations of interleukin (IL)-1, IL-4, IL-6, IL-8, IL-9, IL-15, eotaxin, basic fibroblast growth factor (b-FGF), granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), and tumor necrosis factor-alpha (TNF-α) in the group of severe CAP. Most of these associations persisted when adjusting for age in linear regression analyses. The cytokine response was strongly associated with age but to a lesser extent with viral etiology.

Conclusion

The plasma concentrations of several cytokines, both with pro-inflammatory and anti-inflammatory effects, were higher among children with severe illness. In particular G-CSF and IL-6 reflected severity and might provide complementary information on the severity of the infection.

Trial registration

ClinicalTrials.gov NCT00148733     

Implementation Fidelity of the National Malaria Control Program in Burkina Faso

Background

Every year 40,000 people die of malaria in Burkina Faso. In 2010, the Burkinabè authorities implemented a national malaria control program that provides for the distribution of mosquito nets and the home-based treatment of children with fever by community health workers. The objective of this study was to measure the implementation fidelity of this program.

Methods

We conducted a case study in two comparable districts (Kaya and Zorgho). Data were collected one year after the program’s implementation through field observations (10 weeks), documentary analysis, and individual interviews with stakeholders (n = 48) working at different levels of the program. The analysis framework looked at the fidelity of (i) the intervention’s content, (ii) its coverage, and (iii) its schedule.

Results

The program’s implementation was relatively faithful to what was originally planned and was comparable in the two districts. It encountered certain obstacles in terms of the provision of supplies. Coverage fidelity was better in Kaya than in Zorgho, where many community health workers (CHW) experienced problems with the restocking of artemisinin-based combination therapy and with remuneration for periods of training. In both districts, the community was rarely involved in the process of selecting CHWs. The components affected by scheduling all experienced successive implementation delays that pushed nets distribution and the initial provision of artemisinin-based combination therapies to the CHWs past the 2010 malaria season.

Conclusions

The activities intended by the program were mostly implemented with good fidelity. However, the implementation was plagued by delays that probably postponed the expected beneficial effects.     

Respiratory Viruses Associated Hospitalization among Children Aged <5 Years in Bangladesh: 2010-2014

Background

We combined hospital-based surveillance and health utilization survey data to estimate the incidence of respiratory viral infections associated hospitalization among children aged < 5 years in Bangladesh.

Methods

Surveillance physicians collected respiratory specimens from children aged <5 years hospitalized with respiratory illness and residing in the primary hospital catchment areas. We tested respiratory specimens for respiratory syncytial virus, parainfluenza viruses, human metapneumovirus, influenza, adenovirus and rhinoviruses using rRT-PCR. During 2013, we conducted a health utilization survey in the primary catchment areas of the hospitals to determine the proportion of all hospitalizations for respiratory illness among children aged <5 years at the surveillance hospitals during the preceding 12 months. We estimated the respiratory virus-specific incidence of hospitalization by dividing the estimated number of hospitalized children with a laboratory confirmed infection with a respiratory virus by the population aged <5 years of the catchment areas and adjusted for the proportion of children who were hospitalized at the surveillance hospitals.

Results

We estimated that the annual incidence per 1000 children (95% CI) of all cause associated respiratory hospitalization was 11.5 (10–12). The incidences per 1000 children (95% CI) per year for respiratory syncytial virus, parainfluenza, adenovirus, human metapneumovirus and influenza infections were 3(2–3), 0.5(0.4–0.8), 0.4 (0.3–0.6), 0.4 (0.3–0.6), and 0.4 (0.3–0.6) respectively. The incidences per 1000 children (95%CI) of rhinovirus-associated infections among hospitalized children were 5 (3–7), 2 (1–3), 1 (0.6–2), and 3 (2–4) in 2010, 2011, 2012 and 2013, respectively.

Conclusion

Our data suggest that respiratory viruses are associated with a substantial burden of hospitalization in children aged <5 years in Bangladesh.     

The Clinical and Etiological Characteristics of Influenza-Like Illness (ILI) in Outpatients in Shanghai,China, 2011 to 2013

Introduction

Clinical and etiological characteristics of influenza-like illness (ILI) in outpatients is poorly understood in the southern temperate region of China. We conducted laboratory-based surveillance of viral etiology for ILI outpatients in Shanghai from January 2011 to December 2013.

Materials and Methods

Clinical and epidemiological data from ILI outpatients, both children and adults, were collected. A total of 1970 nasopharyngeal swabs were collected and tested for 12 respiratory viruses using multiplex RT-PCR, and the data were analyzed anonymously.

Results

All 12 respiratory viruses were detected in the specimens. At least one virus was detected in 32.4% of 1970 specimens analyzed, with 1.1% showing co-infections. The most frequently detected agents were influenza A (11.7%), influenza B (9.6%), and rhinoviruses (3.1%).Other viruses were present at a frequency less than 3.0%. We observed a winter peak in the detection rate in ILI patients during 3 years of surveillance and a summer peak in 2012. HCoV, HADV, and HMPV were detected more frequently in children than in adults. Patients infected with influenza virus experienced higher temperatures, more coughs, running noses, headaches and fatigue than patients infected with other viruses and virus-free patients (p<0.001).

Conclusions

The spectrum, seasonality, age distribution and clinical associations of respiratory virus infections in children and adults with influenza-like illness were analyzed in this study for the first time. To a certain extent, the findings can provide baseline data for evaluating the burden of respiratory virus infection in children and adults in Shanghai. It will also provide clinicians with helpful information about the etiological patterns of outpatients presenting with complaints of acute respiratory syndrome, but further studies should be conducted, and longer-term laboratory-based surveillance would give a better picture of the etiology of ILI.     

Etiology and Factors Associated with Pneumonia in Children under 5 Years of Age in Mali: A Prospective Case-Control Study

Background

There are very limited data on children with pneumonia in Mali. The objective was to assess the etiology and factors associated with community-acquired pneumonia in hospitalized children <5 years of age in Mali.

Methods

A prospective hospital-based case-control study was implemented in the Pediatric department of Gabriel Touré University Hospital at Bamako, Mali, between July 2011-December 2012. Cases were children with radiologically-confirmed pneumonia; Controls were hospitalized children without respiratory features, matched for age and period. Respiratory specimens, were collected to identify 19 viruses and 5 bacteria. Whole blood was collected from cases only. Factors associated with pneumonia were assessed by multivariate logistic regression.

Results

Overall, 118 cases and 98 controls were analyzed; 44.1% were female, median age was 11 months. Among pneumonia cases, 30.5% were hypoxemic at admission, mortality was 4.2%. Pneumonia cases differed from the controls regarding clinical signs and symptoms but not in terms of past medical history. Multivariate analysis of nasal swab findings disclosed that S. pneumoniae (adjusted odds ratio [aOR] = 3.4, 95% confidence interval [95% CI]: 1.6–7.0), human metapneumovirus (aOR = 17.2, 95% CI: 2.0–151.4), respiratory syncytial virus [RSV] (aOR = 7.4, 95% CI: 2.3–23.3), and influenza A virus (aOR = 10.7, 95% CI: 1.0–112.2) were associated with pneumonia, independently of patient age, gender, period, and other pathogens. Distribution of S. pneumoniae and RSV differed by season with higher rates of S. pneumoniae in January-June and of RSV in July-September. Pneumococcal serotypes 1 and 5 were more frequent in pneumonia cases than in the controls (P = 0.009, and P = 0.04, respectively).

Conclusions

In this non-PCV population from Mali, pneumonia in children was mainly attributed to S. pneumoniae, RSV, human metapneumovirus, and influenza A virus. Increased pneumococcal conjugate vaccine coverage in children could significantly reduce the burden of pneumonia in sub-Saharan African countries.     

Health Facility Utilisation Changes during the Introduction of Community Case Management of Malaria in South Western Uganda: An Interrupted Time Series Approach

Background

Malaria endemic countries have scaled-up community health worker (CHW) interventions, to diagnose and treat malaria in communities with limited access to public health systems. The evaluations of these programmes have centred on CHW’s compliance to guidelines, but the broader changes at public health centres including utilisation and diagnoses made, has received limited attention.

Methods

This analysis was conducted during a CHW–intervention for malaria in Rukungiri District, Western Uganda. Outpatient department (OPD) visit data were collected for children under-5 attending three health centres one year before the CHW-intervention started (pre-intervention period) and for 20 months during the intervention (intervention-period). An interrupted time series analysis with segmented regression models was used to compare the trends in malaria, non-malaria and overall OPD visits during the pre-intervention and intervention-period.

Results

The introduction of a CHW-intervention suggested the frequency of diagnoses of diarrhoeal diseases, pneumonia and helminths increased, whilst the frequency of malaria diagnoses declined at health centres. In May 2010 when the intervention began, overall health centre utilisation decreased by 63% compared to the pre-intervention period and the health centres saw 32 fewer overall visits per month compared to the pre-intervention period (p<0.001). Malaria visits also declined shortly after the intervention began and there were 27 fewer visits per month during the intervention-period compared with the pre-intervention period (p<0.05). The declines in overall and malaria visits were sustained for the entire intervention-period. In contrast, there were no observable changes in trends of non-malarial visits between the pre-intervention and intervention-period.

Conclusions

This analysis suggests introducing a CHW-intervention can reduce the number of child malaria visits and change the profile of cases presenting at health centres. The reduction in workload of health workers may allow them to spend more time with patients or undertake additional curative or preventative roles.     

Individualizing Risk of Multidrug-Resistant Pathogens in Community-Onset Pneumonia

Introduction

The diffusion of multidrug-resistant (MDR) bacteria has created the need to identify risk factors for acquiring resistant pathogens in patients living in the community.

Objective

To analyze clinical features of patients with community-onset pneumonia due to MDR pathogens, to evaluate performance of existing scoring tools and to develop a bedside risk score for an early identification of these patients in the Emergency Department.

Patients and Methods

This was an open, observational, prospective study of consecutive patients with pneumonia, coming from the community, from January 2011 to January 2013. The new score was validated on an external cohort of 929 patients with pneumonia admitted in internal medicine departments participating at a multicenter prospective study in Spain.

Results

A total of 900 patients were included in the study. The final logistic regression model consisted of four variables: 1) one risk factor for HCAP, 2) bilateral pulmonary infiltration, 3) the presence of pleural effusion, and 4) the severity of respiratory impairment calculated by use of PaO2/FiO2 ratio. A new risk score, the ARUC score, was developed; compared to Aliberti, Shorr, and Shindo scores, this point score system has a good discrimination performance (AUC 0.76, 95% CI 0.71-0.82) and calibration (Hosmer-Lemeshow, χ2 = 7.64; p = 0.469). The new score outperformed HCAP definition in predicting etiology due to MDR organism. The performance of this bedside score was confirmed in the validation cohort (AUC 0.68, 95% CI 0.60-0.77).

Conclusion

Physicians working in ED should adopt simple risk scores, like ARUC score, to select the most appropriate antibiotic regimens. This individualized approach may help clinicians to identify those patients who need an empirical broad-spectrum antibiotic therapy.     

Active Video Game Exercise Training Improves the Clinical Control of Asthma in Children: Randomized Controlled Trial

Objective

The aim of the present study was to determine whether aerobic exercise involving an active video game system improved asthma control, airway inflammation and exercise capacity in children with moderate to severe asthma.

Design

A randomized, controlled, single-blinded clinical trial was carried out. Thirty-six children with moderate to severe asthma were randomly allocated to either a video game group (VGG; N = 20) or a treadmill group (TG; n = 16). Both groups completed an eight-week supervised program with two weekly 40-minute sessions. Pre-training and post-training evaluations involved the Asthma Control Questionnaire, exhaled nitric oxide levels (FeNO), maximum exercise testing (Bruce protocol) and lung function.

Results

No differences between the VGG and TG were found at the baseline. Improvements occurred in both groups with regard to asthma control and exercise capacity. Moreover, a significant reduction in FeNO was found in the VGG (p < 0.05). Although the mean energy expenditure at rest and during exercise training was similar for both groups, the maximum energy expenditure was higher in the VGG.

Conclusion

The present findings strongly suggest that aerobic training promoted by an active video game had a positive impact on children with asthma in terms of clinical control, improvementin their exercise capacity and a reductionin pulmonary inflammation.

Trial Registration

Clinicaltrials.gov NCT01438294     

Severe Community-Acquired Pneumonia Caused by Human Adenovirus in Immunocompetent Adults: A Multicenter Case Series

Background

Severe community-acquired pneumonia (CAP) caused by human adenovirus (HAdV), especially HAdV type 55 (HAdV-55) in immunocompetent adults has raised increasing concerns. Clinical knowledge of severe CAP and acute respiratory distress syndrome induced by HAdV-55 is still limited, though the pathogen has been fully characterized by whole-genome sequencing.

Methods

We conducted a multicentre retrospective review of all consecutive patients with severe CAP caused by HAdV in immunocompetent adults admitted to the Emergency Department Intensive Care Unit of two hospitals in Northern China between February 2012 and April 2014. Clinical, laboratory, radiological characteristics, treatments and outcomes of these patients were collected and analyzed.

Results

A total of 15 consecutive severe CAP patients with laboratory-confirmed adenovirus infections were included. The median age was 30 years and all cases were identified during the winter and spring seasons. HAdV-55 was the most frequently (11/15) detected HAdV type. Persistent high fever, cough and rapid progression of dyspnea were typically reported in these patients. Significantly increased pneumonia severity index (PSI), respiratory rate, and lower PaO₂/FiO₂, hypersensitive CRP were reported in non-survivors compared to survivors (P = 0.013, 0.022, 0.019 and 0.026, respectively). The rapid development of bilateral consolidations within 10 days after illness onset were the most common radiographic finding, usually accompanied by adjacent ground glass opacities and pleural effusions. Total mortality was 26.7% in this study. Corticosteroids were prescribed to 14 patients in this report, but the utilization rate between survivors and non-survivors was not significant.

Conclusions

HAdV and the HAdV-55 sub-type play an important role among viral pneumonia pathogens in hospitalized immunocompetent adults in Northern China. HAdV should be tested in severe CAP patients with negative bacterial cultures and a lack of response to antibiotic treatment, even if radiologic imaging and clinical presentation initially suggest bacterial pneumonia.