Pneumonia In Bangladesh Research Articles

Multi-drug Resistant Mannheimia hemolytica and Pasteurella multocida in Pneumonic Sheep in Bangladesh

Background: Pneumonia in sheep is a complicated multicausal disease which affects the respiratory system causing increased morbidity and herd mortality rate. The members of Pasteurellaceae family are one of the prime causes of bacterial pneumonia in ruminants. Once infected by these organisms, antimicrobial therapy becomes obligatory. In Bangladesh, causation of pneumonic pasteurellosis and their antibiogram is unknown in sheep which insists the veterinarians to choose empirical antimicrobial therapy. Objectives: This study was undertaken to identify multidrug resistant Pasteurella multocida and Mannheimia hemolytica in sheep suspected with pneumonia. Methodology: The samples of nasal swab and the lungs were collected aseptically. After overnight incubation in Brain Heart Infusion broth, the samples were streaked onto 5.0% sheep Blood Agar to obtain pure colony with characteristic features which were subjected to biochemical tests, polymerase chain reaction (PCR), and antibiogram study against eight antibiotics. Results: A total number of 140 samples were collected of which 120 nasal swabs and 20 lungs were collected aseptically. In total, 16.7% pneumonia cases in sheep were found to be caused by Pasteurella species. Out of 140 samples, 43.57% (61/140) were positive for Mannheimia hemolytica (68.85%) and 19.67% for Pasteurella multocida. The mixed infection by both organisms was 11.48%. The Mannheimia hemolytica (MH) was predominant in lungs (100.0%) and nasal swab samples (18.3%) than Pasteurella multocida (PM) which were 15% and 7.5% respectively. All the isolates were found to be multi-drug resistant where resistance against Penicillin and Ampicillin was 100% for all isolates. The resistance of Mannheimia hemolytica and Pasteurella multocida towards sulfonamide, ceftriaxone, oxytetracycline, gentamicin, and streptomycin were 63.33%, 49.44%, 44.44%. 16.67%, 11.11% and 78.22%, 45.46%, 45.45%, 36.36%, 27.27% respectively. Among all antibiotics tested, Chloramphenicol stands out to be the most effective one (100% sensitive). Conclusion: This study states the first molecular identification of Mannheimia hemolytica and Pasteurella multocida from sheep suspected with pneumonia in Bangladesh and their antibiogram pattern against commonly prescribed antimicrobials. Due to their commensalism nature and wide host coverage, these MDR pathogens warrant judicious use of antibiotics in small ruminants to reduce veterinary public health hazard. Bangladesh Journal of Infectious Diseases, June 2023;10(1):16-23

Clinical hypoxemia score for outpatient child pneumonia care lacking pulse oximetry in Africa and South Asia.

Pulse oximeters are not routinely available in outpatient clinics in low- and middle-income countries. We derived clinical scores to identify hypoxemic child pneumonia. This was a retrospective pooled analysis of two outpatient datasets of 3-35 month olds with World Health Organization (WHO)-defined pneumonia in Bangladesh and Malawi. We constructed, internally validated, and compared fit & discrimination of four models predicting SpO2 < 93% and <90%: (1) Integrated Management of Childhood Illness guidelines, (2) WHO-composite guidelines, (3) Independent variable least absolute shrinkage and selection operator (LASSO); (4) Composite variable LASSO. 12,712 observations were included. The independent and composite LASSO models discriminated moderately (both C-statistic 0.77) between children with a SpO2 < 93% and ≥94%; model predictive capacities remained moderate after adjusting for potential overfitting (C-statistic 0.74 and 0.75). The IMCI and WHO-composite models had poorer discrimination (C-statistic 0.56 and 0.68) and identified 20.6% and 56.8% of SpO2 < 93% cases. The highest score stratum of the independent and composite LASSO models identified 46.7% and 49.0% of SpO2 < 93% cases. Both LASSO models had similar performance for a SpO2 < 90%. In the absence of pulse oximeters, both LASSO models better identified outpatient hypoxemic pneumonia cases than the WHO guidelines. Score external validation and implementation are needed.

Derivation and validation of a clinical prediction model for risk-stratification of children hospitalized with severe pneumonia in Bangladesh.

Children with severe pneumonia in low- and middle-income countries (LMICs) suffer from high rates of treatment failure despite appropriate World Health Organization (WHO)-directed antibiotic treatment. Developing a clinical prediction rule for treatment failure may allow early identification of high-risk patients and timely intervention to decrease mortality. We used data from two separate studies conducted at the Dhaka Hospital of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) to derive and externally validate a clinical prediction rule for treatment failure of children hospitalized with severe pneumonia. The derivation dataset was from a randomized clinical trial conducted from 2018 to 2019, studying children aged 2 to 59 months hospitalized with severe pneumonia as defined by WHO. Treatment failure was defined by the persistence of danger signs at the end of 48 hours of antibiotic treatment or the appearance of any new danger signs within 24 hours of enrollment. We built a random forest model to identify the top predictors. The top six predictors were the presence of grunting, room air saturation, temperature, the presence of lower chest wall indrawing, the presence of respiratory distress, and central cyanosis. Using these six predictors, we created a parsimonious model with a discriminatory performance of 0.691, as measured by area under the receiving operating curve (AUC). We performed external validation using a temporally distinct dataset from a cohort study of 191 similarly aged children with severe acute malnutrition and pneumonia. In external validation, discriminatory performance was maintained with an improved AUC of 0.718. In conclusion, we developed and externally validated a parsimonious six-predictor model using random forest methods to predict treatment failure in young children with severe pneumonia in Bangladesh. These findings can be used to further develop and validate parsimonious and pragmatic prognostic clinical prediction rules for pediatric pneumonia, particularly in LMICs.

Diagnosis of a case of X-linked agammaglobulinemia with juvenile idiopathic arthritis and recurrent pneumonia in Bangladesh

Abstract X-linked agammaglobulinemia (XLA) is a rare hereditary primary immunodeficiency disorder caused by mutation in the Bruton’s tyrosine kinase (BTK) gene located in the Xq22 region of the X chromosome. It is characterized by absolute or marked deficiency of matured B-cells in circulation as well as decreased in all immunoglobulin (Ig) classes. We have reported one case who is a 48-month-old boy and suffering from recurrent pneumonia, skin abscess, otitis media, and swelling of the left knee joint. His serum Ig levels showed an IgM level of &lt;0.169 g/l, IgG 2.43 g/l, and IgA &lt;0.256 g/l. Immunophenotyping of lymphocyte subsets showed an absence of B-cells. Intracellular BTK protein expression in monocytes by flow cytometry showed a markedly reduced mean fluorescence index which confirmed the diagnosis of XLA. Antibiotics with intravenous Ig therapy were started.

Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study

Hypoxaemic pneumonia mortality risk in low-income and middle-income countries is high in children who have been hospitalised, but unknown among outpatient children. We sought to establish the outpatient burden, mortality risk, and prognostic accuracy of death from hypoxaemia in children with suspected pneumonia in Bangladesh. We conducted a prospective community-based cohort study encompassing three upazila (subdistrict) health complex catchment areas in Sylhet, Bangladesh. Children aged 3-35 months participating in a community surveillance programme and presenting to one of three upazila health complex Integrated Management of Childhood Illness (IMCI) outpatient clinics with an acute illness and signs of difficult breathing (defined as suspected pneumonia) were enrolled in the study; because lower respiratory tract infection mortality mainly occurs in children younger than 1 year, the primary study population comprised children aged 3-11 months. Study physicians recorded WHO IMCI pneumonia guideline clinical signs and peripheral arterial oxyhaemoglobin saturations (SpO2) in room air. They treated children with pneumonia with antibiotics (oral amoxicillin [40 mg/kg per dose twice per day for 5-7 days, as per local practice]), and recommended oxygen, parenteral antibiotics, and hospitalisation for those with an SpO2 of less than 90%, WHO IMCI danger signs, or severe malnutrition. Community health workers documented the children's vital status and the date of any vital status changes during routine household surveillance (one visit to each household every 2 months). The primary outcome was death at 2 weeks after enrolment in children aged 3-11 months (primary study population) and 12-35 months (secondary study population). Primary analyses included estimating the outpatient prevalence, mortality risk, and prognostic accuracy of hypoxaemia for death in children aged 3-11 months with suspected pneumonia. Risk ratios were produced by fitting a multivariable model that regressed predefined SpO2 ranges (<90%, 90-93%, and 94-100%) on the primary 2-week mortality outcome (binary outcome) using Poisson models with robust variance estimation. We established the prognostic accuracy of WHO IMCI guidelines for death with and without varying SpO2 thresholds. Participants were recruited between Sept 1, 2015, to Aug 31, 2017. During the study period, a total of 7440 children aged 3-35 months with the first suspected pneumonia episode were enrolled, of whom 3848 (54·3%) with an attempted pulse oximeter measurement and 2-week outcome were included in our primary study population of children aged 3-11-months. Among children aged 3-11 months, an SpO2 of less than 90% occurred in 102 (2·7%) of 3848 children, an SpO2 of 90-93% occurred in 306 (8·0%) children, a failed SpO2 measurement occurred in 67 (1·7%) children, and 24 (0·6%) children with suspected pneumonia died. Compared with an SpO2 of 94-100% (3373 [87·7%] of 3848), the adjusted risk ratio for death was 10·3 (95% CI 3·2-32·3; p<0·001) for an SpO2 of less than 90%, 4·3 (1·5-11·8; p=0·005) for an SpO2 of 90-93%, and 11·4 (3·1-41·4; p<0·001) for a failed measurement. When not considering pulse oximetry, of the children who died, WHO IMCI guidelines identified only 25·0% (95% CI 9·7-46·7; six of 24 children) as eligible for referral to hospital. For identifying deaths, in children with an SpO2 of less than 90% WHO IMCI guidelines had a 41·7% sensitivity (95% CI 22·1-63·4) and 89·7% specificity (88·7-90·7); for children with an SpO2 of less than 90% or measurement failure the guidelines had a 54·2% sensitivity (32·8-74·4) and 88·3% specificity (87·2-89·3); and for children with an SpO2 of less than 94% or measurement failure the guidelines had a 62·5% sensitivity (40·6-81·2) and 81·3% specificity (80·0-82·5). These findings support pulse oximeter use during the outpatient care of young children with suspected pneumonia in Bangladesh as well as the re-evaluation of the WHO IMCI currently recommended threshold of an SpO2 less than 90% for hospital referral. Fogarty International Center of the National Institutes of Health (K01TW009988), The Bill & Melinda Gates Foundation (OPP1084286 and OPP1117483), and GlaxoSmithKline (90063241).

Community Acquired Pneumonia in Bangladesh: Sensitivity Pattern, Clinical Courses and Outcome of a Cross Sectional Population

Background: Pneumonia acquired outside the hospital by an immune-competent individual is defined as community acquired pneumonia (CAP). It is to be distinguished, on the basis of a wider spectrum of pathogens, from nosocomial pneumonia from pneumonia in an immune-compromised host. Community-acquired pneumonia is associated with a significant mortality and morbidity. Etiology of CAP varies geographically and the understanding of local epidemiology plays an important role in decision making for empirical treatment before test results are available. Primary decisions about empirical antimicrobial treatment required knowledge of predominant microbial patterns and their sensitivities.&#x0D; Objectives: The aim of this study was to identify the bacterial etiology of CAP, their sensitivity towards empirical therapy and to observe the clinical course as well as short term outcome in hospitalized adult patients.&#x0D; Methodology: It was one year-long observational prospective study on 87 patients diagnosed with CAP admitted in Chattogram Medical College Hospital, second largest tertiary care hospital during August 2018 to July 2019. Sputum for Gram and Z-N staining, culture and sensitivity, blood for culture, sensitivity and PCR for Streptococcus pneumonia, Mycoplasma pneumoniae, Legionella pneumophila and Chlamydophila pneumonia were done. Patients were followed up for in-hospital outcome and 30-day mortality.&#x0D; Results: The mean age was 49.59 years and male - female ratio was 1.56: 1. Fever, chest pain and cough were the most common clinical findings. Klebsiella pneumoniae was identified (39.1%) in the majority of the patients, followed by Pseudomonas aeruginosa (10.3%), Staphylococcus aureus and Escherichia coli (5.7%). Staphylococcus aureus was positive in blood culture of one patient. Four samples were positive in PCR and identified Streptococcus pneumoniae. The sensitivity to meropenem, levofloxacin and amikacin was highest. The mean duration of hospital stay was 6.34 ± 2.37 days along with in-hospital mortality and 30-day mortality was 6.9% and 16.1% respectively.&#x0D; Conclusion: The bacteriologic profile of community acquired pneumonia revealed Gram-negative bacteria as pre-dominant organism by conventional sputum and blood culture. But need for further serologic tests for atypical and viral pathogens and development of institutional antibiogram to facilitate the choice for empirical therapy is required.

Hypoxaemia prevalence and its adverse clinical outcomes among children hospitalised with WHO-defined severe pneumonia in Bangladesh.

BackgroundWith an estimated 1 million cases per year, pneumonia accounts for 15% of all under-five deaths globally, and hypoxaemia is one of the strongest predictors of mortality. Most of these deaths are preventable and occur in low- and middle-income countries. Bangladesh is among the six high burden countries with an estimated 4 million pneumonia episodes annually. There is a gap in updated evidence on the prevalence of hypoxaemia among children with severe pneumonia in high burden countries, including Bangladesh.MethodsWe conducted a secondary analysis of data obtained from icddr,b-Dhaka Hospital, a secondary level referral hospital located in Dhaka, Bangladesh. We included 2646 children aged 2-59 months admitted with WHO-defined severe pneumonia during 2014-17. The primary outcome of interest was hypoxaemia, defined as SpO2 < 90% on admission. The secondary outcome of interest was adverse clinical outcomes defined as deaths during hospital stay or referral to higher-level facilities due to clinical deterioration.ResultsOn admission, the prevalence of hypoxaemia among children hospitalised with severe pneumonia was 40%. The odds of hypoxaemia were higher among females (adjusted Odds ratio AOR = 1.44; 95% confidence interval CI = 1.22-1.71) and those with a history of cough or difficulty in breathing for 0-48 hours before admission (AOR = 1.61; 95% CI = 1.28-2.02). Among all children with severe pneumonia, 6% died during the hospital stay, and 9% were referred to higher-level facilities due to clinical deterioration. Hypoxaemia was the strongest predictor of mortality (AOR = 11.08; 95% CI = 7.28-16.87) and referral (AOR = 5.94; 95% CI = 4.31-17) among other factors such as age, sex, history of fever and cough or difficulty in breathing, and severe acute malnutrition. Among those who survived, the median duration of hospital stay was 7 (IQR = 4-11) days in the hypoxaemic group and 6 (IQR = 4-9) days in the non-hypoxaemic group, and the difference was significant at P < 0.001.ConclusionsThe high burden of hypoxaemia and its clinical outcomes call for urgent attention to promote oxygen security in low resource settings like Bangladesh. The availability of pulse oximetry for rapid identification and an effective oxygen delivery system for immediate correction should be ensured for averting many preventable deaths.

The Etiology of Childhood Pneumonia in Bangladesh: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study.

Pneumonia remains the leading infectious cause of death among children <5 years, but its cause in most children is unknown. We estimated etiology for each child in 2 Bangladesh sites that represent rural and urban South Asian settings with moderate child mortality. As part of the Pneumonia Etiology Research for Child Health study, we enrolled children 1-59 months of age with World Health Organization-defined severe and very severe pneumonia, plus age-frequency-matched controls, in Matlab and Dhaka, Bangladesh. We applied microbiologic methods to nasopharyngeal/oropharyngeal swabs, blood, induced sputum, gastric and lung aspirates. Etiology was estimated using Bayesian methods that integrated case and control data and accounted for imperfect sensitivity and specificity of the measurements. We enrolled 525 cases and 772 controls over 24 months. Of the cases, 9.1% had very severe pneumonia and 42.0% (N = 219) had infiltrates on chest radiograph. Three cases (1.5%) had positive blood cultures (2 Salmonella typhi, 1 Escherichia coli and Klebsiella pneumoniae). All 4 lung aspirates were negative. The etiology among chest radiograph-positive cases was predominantly viral [77.7%, 95% credible interval (CrI): 65.3-88.6], primarily respiratory syncytial virus (31.2%, 95% CrI: 24.7-39.3). Influenza virus had very low estimated etiology (0.6%, 95% CrI: 0.0-2.3). Mycobacterium tuberculosis (3.6%, 95% CrI: 0.5-11.0), Enterobacteriaceae (3.0%, 95% CrI: 0.5-10.0) and Streptococcus pneumoniae (1.8%, 95% CrI: 0.0-5.9) were the only nonviral pathogens in the top 10 etiologies. Childhood severe and very severe pneumonia in young children in Bangladesh is predominantly viral, notably respiratory syncytial virus.

Antibiotic-Resistant Bacteremia in Young Children Hospitalized With Pneumonia in Bangladesh Is Associated With a High Mortality Rate.

BackgroundPneumonia is a leading cause of sepsis and mortality in children under 5 years. However, our understanding of the causes of bacteremia in children with pneumonia is limited.MethodsWe characterized risk factors for bacteremia and death in a cohort of children admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) between 2014 and 2017 with radiographically confirmed pneumonia.ResultsA total of 4007 young children were hospitalized with pneumonia over the study period. A total of 1814 (45%) had blood cultures obtained. Of those, 108 (6%) were positive. Gram-negative pathogens predominated, accounting for 83 (77%) of positive cultures. These included Pseudomonas (N = 22), Escherichia coli (N = 17), Salmonella enterica (N = 14, including 11 Salmonella Typhi), and Klebsiella pneumoniae (N = 11). Gram-positive pathogens included Pneumococcus (N = 7) and Staphylococcus aureus (N = 6). Resistance to all routinely used empiric antibiotics (ampicillin, gentamicin, ciprofloxacin, and ceftriaxone) for children with pneumonia at the icddr,b was observed in 20 of the 108 isolates. Thirty-one of 108 (29%) children with bacteremia died, compared to 124 of 1706 (7%) who underwent culture without bacteremia (odds ratio [OR], 5.1; 95% confidence interval [CI], 3.3–8.1; P < .001). Children infected with bacteria resistant to all routinely used empiric antibiotics were at greater risk of death compared to children without bacteremia (OR, 17.3; 95% CI, 7.0–43.1; P < .001).ConclusionsAntibiotic-resistant Gram-negative bacteremia in young children with pneumonia in Dhaka, Bangladesh was associated with a high mortality rate. The pandemic of antibiotic resistance is shortening the lives of young children in Bangladesh, and new approaches to prevent and treat these infections are desperately needed.

Household economic burden of childhood severe pneumonia in Bangladesh: a cost-of-illness study

ObjectiveTo estimate household cost of illness (COI) for children with severe pneumonia in Bangladesh.DesignAn incidence-based COI study was performed for one episode of childhood severe pneumonia from a household perspective....

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

What is already known on this topic?Different socioecological factors were associated with childhood pneumonia in Bangladesh. However, previous studies did not assess spatial patterns, and socioecological factors and spatial variation have the potential to improve the accuracy and predictive ability of existing models.What is added by this report?The spatial random effects were present at the district level and were heterogeneous. Average temperature, temperature variation, and population density may influence the spatial pattern of childhood pneumonia in Bangladesh.What are the implications for public health practice?The study results will help policymakers and health managers to identify the vulnerable districts, plan further investigations, help to improve proper resource allocation, and improve health interventions.

Effectiveness of the 10-valent pneumococcal conjugate vaccine against radiographic pneumonia among children in rural Bangladesh: A case-control study

BackgroundPneumococcal conjugate vaccine (PCV) effectiveness against radiographic pneumonia in South Asia is unknown. Bangladesh introduced PCV10 in 2015 using a three dose primary series (3 + 0). We sought to measure PCV10 effectiveness for two or more vaccine doses on radiographic pneumonia among vaccine-eligible children in rural Bangladesh. MethodsWe conducted a matched case-control study over two years from 2015 to 2017 using clinic and community controls in three subdistricts of Sylhet, Bangladesh. Cases were vaccine eligible 3–35 month olds at Upazila Health Complex outpatient clinics with World Health Organization-defined radiographic primary endpoint pneumonia (radiographic pneumonia). Clinic controls were matched to cases within a one week time window by age, sex, and clinic and had an illness unlikely to be Streptococcus pneumoniae; community controls were healthy and similarly matched within a one week time window by age and sex, and distance from the clinic. We estimated adjusted vaccine effectiveness (aVE) using conditional logistic regression. ResultsWe matched 1262 cases with 2707 clinic and 2461 community controls. Overall, aVE using clinic controls was 21.4% (95% confidence interval, −0.2%, 38.4%) for ≥2 PCV10 doses and among 3–11 month olds was 47.3% (10.5%, 69.0%) for three doses. aVE increased with higher numbers of doses in clinic control sets (p = 0.007). In contrast, aVE using community controls was 7.6% (95% confidence interval, −22.2%, 30.0%) for ≥2 doses. We found vaccine introduction in the study area faster and less variable than expected with 75% coverage on average, which reduced power. Information bias may also have affected community controls. ConclusionsClinic control analyses show PCV10 prevented radiographic pneumonia in Bangladesh, especially among younger children receiving three doses. While both analyses were underpowered, community control enrollment – compared to clinic controls – was more difficult in a complex, pluralistic healthcare system. Future studies in comparable settings may consider alternative study designs.

Awareness Among Parents About Pneumococcal Conjugate Vaccine in Routine Immunization Program to Prevent Pneumococcal Pneumonia in Bangladesh.

IntroductionThis study was conducted in two purposively selected slums of Dhaka to assess parents’ awareness of pneumococcal conjugate vaccine (PCV) in reducing the occurrence of death due to pneumococcal pneumonia.MethodsUsing a semi-structured questionnaire, face-to-face interviews were conducted with 150 parents. Data were analyzed using Statistical Package for the Social Sciences (SPSS), version 20 (IBM Corp., Armonk, NY) and Chi-square (χ2) test performed to determine associations.ResultsAbout 35% of parents were found to be aware of PCV; of them, 92.5% were informed by health service providers, and 81.1% mentioned benefits of PCV. Most parents were unaware of the PCV vaccination status of children, and no significant association was found between vaccination status and parents’ socioeconomic status. Aware parents vaccinated their children, and the association of awareness with vaccination status was statistically significant for PCV-1 (P = 0.04) and PCV-2 (P < 0.001). Although 7.4% of parents did not vaccinate their child with PCV-3 due to a child’s sickness or other priorities in household work, the association was significant (P = 0.01).ConclusionStrengthened efforts by health service providers, prioritizing dissemination of key messages on PCV, its benefits, and side-effects, can motivate parents and reduce dropout rates.

Post-discharge mortality in children with severe malnutrition and pneumonia in Bangladesh.

BackgroundPost-discharge mortality among children with severe illness in resource-limited settings is under-recognized and there are limited data. We evaluated post-discharge mortality in a recently reported cohort of children with severe malnutrition and pneumonia, and identified characteristics associated with an increased risk of death.MethodsYoung children (<5 years of age) with severe malnutrition (WHO criteria) and radiographic pneumonia on admission to Dhaka Hospital of icddr,b over a 15-month period were managed according to standard protocols. Those discharged were followed-up and survival status at 12 weeks post-discharge was determined. Verbal autopsy was requested from families of those that died.ResultsOf 405 children hospitalized with severe malnutrition and pneumonia, 369 (median age, 10 months) were discharged alive with a follow-up plan. Of these, 32 (8.7%) died in the community within 3 months of discharge: median 22 (IQR 9–35) days from discharge to death. Most deaths were reportedly associated with acute onset of new respiratory or gastrointestinal symptoms. Those that died following discharge were significantly younger (median 6 [IQR 3,12] months) and more severely malnourished, on admission and on discharge, than those that survived. Bivariate analysis found that severe wasting on admission (OR 3.64, 95% CI 1.66–7.97) and age <12 months (OR 2.54, 95% CI 1.1–8.8) were significantly associated with post-discharge death. Of those that died in the community, none had attended a scheduled follow-up and care-seeking from a traditional healer was more common (p<0.001) compared to those who survived.Conclusion and SignificancePost-discharge mortality was common in Bangladeshi children following inpatient care for severe malnutrition and pneumonia. The underlying contributing factors require a better understanding to inform the potential of interventions that could improve survival.

Outpatient treatment of children with severe pneumonia with oral amoxicillin in four countries: the MASS study

A recent randomized clinical trial demonstrated home-based treatment of WHO-defined severe pneumonia with oral amoxicillin was equivalent to hospital-based therapy and parenteral antibiotics. We aimed to determine whether this finding is generalizable across four countries. Multicentre observational study in Bangladesh, Egypt, Ghana and Vietnam between November 2005 and May 2008. Children aged 3-59 months with WHO-defined severe pneumonia were enrolled at participating health centres and managed at home with oral amoxicillin (80-90 mg/kg per day) for 5 days. Children were followed up at home on days 1, 2, 3 and 6 and at a facility on day 14 to look for cumulative treatment failure through day 6 and relapse between days 6 and 14. Of 6582 children screened, 873 were included, of whom 823 had an outcome ascertained. There was substantial variation in presenting characteristics by site. Bangladesh and Ghana had fever (97%) as a more common symptom than Egypt (74%) and Vietnam (66%), while in Vietnam, audible wheeze was more common (49%) than at other sites (range 2-16%). Treatment failure by day 6 was 9.2% (95% CI: 7.3-11.2%) across all sites, varying from 6.4% (95% CI: 3.1-9.8%) in Ghana to 13.2% (95% CI: 8.4-18.0%) in Vietnam; 2.7% (95% CI: 1.5-3.9%) of the 733 children well on day 6 relapsed by day 14. The most common causes of treatment failure were persistence of lower chest wall indrawing (LCI) at day 6 (3.8%; 95% CI: 2.6-5.2%), abnormally sleepy or difficult to wake (1.3%; 95% CI: 0.7-2.3%) and central cyanosis (1.3%; 95% CI: 0.7-2.3%). All children survived and only one adverse drug reaction occurred. Treatment failure was more frequent in young infants and those presenting with rapid respiratory rates. Clinical treatment failure and adverse event rates among children with severe pneumonia treated at home with oral amoxicillin did not substantially differ across geographic areas. Thus, home-based therapy of severe pneumonia can be applied to a wide variety of settings.

Coping strategies for financial burdens in families with childhood pneumonia in Bangladesh.

BackgroundThis study aimed to determine the out-of pocket expenditure and coping strategies adopted by families of children admitted in a hospital in Bangladesh with pneumonia.MethodsTrained interviewers surveyed parents of 90 children and conducted in-depth interviews with six families below the age of 5 years who were admitted to the largest pediatric hospital in Bangladesh with a diagnosis of pneumonia. We estimated the total cost of illness associated with hospitalization and explored the coping strategies of the families.ResultsThe mean expenditure of the families for the illness episode was US$ 94 (±SD 52.5) with 75% having spent more than half of their total monthly expenditure on this hospitalization. Three fourths (68/90, 76%) of the families managed the expenditure by borrowing, mortgaging or selling assets; 64% had to borrow the full cost of hospitalization and 10% borrowed from the formal sector with a monthly interest rate of 5 to 30%. The burden was highest for the people from poor income strata. Families earning ≤US$ 59 per month were 10 times more likely than families earning ≥US$ 59 per month to borrow money (OR = 10.0, 95% CI: 2.8-38.8). To repay their debts, 22% of families reported that they would work extra hours and 50% planned to reduce spending on food and education for their children.ConclusionsCoping strategies adopted by the families to manage the out-of-pocket expenditure for children requiring hospitalization were catastrophic for the majority of the families. Efforts to prevent childhood pneumonia for example, by vaccination against the most common pathogens, by improving air quality and by improving childhood nutrition can provide a double advantage. They can prevent both disease and poverty.

Randomized Controlled Trial of Day Care Versus Hospital Care of Severe Pneumonia in Bangladesh

A randomized controlled trial compared day care versus hospital care management of pneumonia. Children 2 to 59 months of age with severe pneumonia received either day care, with antibiotic treatment, feeding, and supportive care from 8:00 am to 5:00 pm, or hospital care, with similar 24-hour treatment. In 2006-2008, 360 children were assigned randomly to receive either day care or hospital care; 189 (53%) had hypoxemia, with a mean±SD oxygen saturation of 93±4%, which increased to 99±1% after oxygen therapy. The mean±SD durations of day care and hospital care were 7.1±2.3 and 6.5±2.8 days, respectively. Successful management was possible for 156 (87.7% [95% confidence interval [CI]: 80.9%-90.9%]) of 180 children in the day care group and 173 (96.1% [95% CI: 92.2%-98.1%]) of 180 children in the hospital care group (P=.001). Twenty-three children in the day care group (12.8% [95% CI: 8.7%-18.4%] and 4 children in the hospital care group (2.2% [95% CI: 0.9%-5.6%] required referral to hospitals (P<.001). During the follow-up period, 22 children in the day care group (14.1% [95% CI: 9.5%-20.4%]) and 11 children in the hospital care group (6.4% [95% CI: 3.6%-11%]) required readmission to hospitals (P=.01). The estimated costs per child treated successfully at the clinic and the hospital were US$114 and US$178, respectively. Severe childhood pneumonia without severe malnutrition can be successfully managed at day care clinics, except for children with hypoxemia who require prolonged oxygen therapy.

Randomized Controlled Trial of Day Care Versus Hospital Care of Severe Pneumonia in Bangladesh

Randomized Controlled Trial of Day Care Versus Hospital Care of Severe Pneumonia in Bangladesh

Multihospital Surveillance of Pneumonia Burden among Children Aged &lt;5 Years Hospitalized for Pneumonia in Bangladesh

Pneumonia contributes substantially to childhood mortality in Bangladesh. We conducted a study to characterize the disease severity and risk factors for mortality among children hospitalized for pneumonia in Bangladesh. We analyzed data on hospitalization, patient characteristics, and mortality collected by a multicenter hospital-based surveillance of pneumonia in Bangladesh. From May 2004 through April 2007, 4155 children aged 2-59 months who met a pneumonia case definition adopted by GAVI's Pneumococcal Vaccines Accelerated Development and Introduction Plan-sponsored surveillance networks were enrolled after blood culture specimens were obtained. The mean duration (+/-SD) from illness onset to hospital admission was 6+/- days; 1842 children (44%) received antimicrobial treatment before hospitalization, and an additional 924 (22%) received antimicrobial treatment after admission to the hospital. Bacteria were isolated from 161 (4%) of the 4155 specimens, including 10 (6%) Streptococcus pneumoniae isolates and 5 (3%) Haemophilus influenzae type b isolates. The case-fatality rate for pneumonia in the hospital was 4% (150 deaths), and the children who died did so after a median of 2 days of hospitalization (range, 0-24 days). Infancy was highly associated with death due to pneumonia (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.2), as were very severe pneumonia (OR, 7.9; 95% CI, 5.6-11.2), a blood culture positive for bacteria (OR, 3.4; 95% CI, 2.0-5.8), severe malnutrition (OR, 4.6; 95% CI, 2.9-7.4), and delayed admission (mean [+/-SD] duration from illness onset to admission, 6+/-6 days, compared with 5+/-4 days for survivors; P< .04). The prevalence of pneumonia among children aged <5 years in hospitals in Bangladesh is high. However, the isolation rate of bacteria is low, possibly because of the high (68%) background use of antibiotics. Multiple risk factors associated with pneumonia case fatality suggest multiple strategies, including vaccines, to reduce pneumonia-related and overall child mortality in Bangladesh.

Care at first-level facilities for children with severe pneumonia in Bangladesh: a cohort study

Guidelines on integrated management of childhood illness (IMCI) for severe pneumonia recommend referral to hospitals. However, in many settings, children who are referred do not actually attend hospital, which severely limits appropriate care. We aimed to assess the safety and effectiveness of modified guidelines that allowed most children with severe pneumonia to be treated locally in first-level facilities, with referral only for those with danger signs or other severe classifications. We did an observational cohort study in ten first-level health facilities in Matlab, rural Bangladesh that had implemented IMCI guidelines. We assessed children with severe pneumonia who were aged between 2 and 59 months, and for whom we could obtain complete information, in two cohorts: 261 children who presented to these facilities between May, 2003, and April, 2004 (before implementation of the modified guidelines) and 1271 children between September, 2004, and August, 2005 (after full implementation). We obtained information about the characteristics and management of their illness, including referrals and admissions to hospital, from facility records. Staff visited households to obtain details of treatment, socioeconomic information, and final outcome, including mortality data. 245 (94%) of 261 children who had severe pneumonia were referred to hospital before the guidelines were modified, compared with 107 (8%) of 1271 after implementation (p<0.0001). 94 (36%) children with severe pneumonia received correct management before the guidelines were modified, compared with 1145 (90%) children after implementation (p<0.0001). Before modification of the guidelines, three children with severe pneumonia who presented at first-level facilities died, with a case-fatality rate of 1.1%; after modification, seven children died, with a case-fatality rate of 0.6% (p=0.39). Local adaptation of the IMCI guidelines, with appropriate training and supervision, could allow safe and effective management of severe pneumonia, especially if compliance with referral is difficult because of geographic, financial, or cultural barriers.