Pneumonia In Malawi Research Articles

Antibiotic treatment failure in children aged 1 to 59 months with World Health Organization-defined severe pneumonia in Malawi: A CPAP IMPACT trial secondary analysis.

Pneumonia is a leading cause of mortality in children <5 years globally. Early identification of hospitalized children with pneumonia who may fail antibiotics could improve outcomes. We conducted a secondary analysis from the Malawi CPAP IMPACT trial evaluating risk factors for antibiotic failure among children hospitalized with pneumonia. Participants were 1-59 months old with World Health Organization-defined severe pneumonia and hypoxemia, severe malnutrition, and/or HIV exposure/infection. All participants received intravenous antibiotics per standard care. First-line antibiotics were benzylpenicillin and gentamicin for five days. Study staff assessed patients for first-line antibiotic failure daily between days 3-6. When identified, patients failing antibiotics were switched to second-line ceftriaxone. Analyses excluded children receiving ceftriaxone and/or deceased by hospital day two. We compared characteristics between patients with and without treatment failure and fit multivariable logistic regression models to evaluate associations between treatment failure and admission characteristics. From June 2015-March 2018, 644 children were enrolled and 538 analyzed. Antibiotic failure was identified in 251 (46.7%) participants, and 19/251 (7.6%) died. Treatment failure occurred more frequently with severe malnutrition (50.2% (126/251) vs 28.2% (81/287), p<0.001) and amongst those dwelling ≥10km from a health facility (22.3% (56/251) vs 15.3% (44/287), p = 0.026). Severe malnutrition occurred more frequently among children living ≥10km from a health facility than those living <10km (49.0% (49/100) vs 35.7% (275/428), p = 0.014). Children with severe malnutrition (adjusted odds ratio (aOR) 2.2 (95% CI 1.52, 3.24), p<0.001) and pre-hospital antibiotics ((aOR 1.47, 95% CI 1.01, 2.14), p = 0.043) had an elevated aOR for antibiotic treatment failure. Severe malnutrition and pre-hospital antibiotic use predicted antibiotic treatment failure in this high-risk severe pneumonia pediatric population in Malawi. Our findings suggest addressing complex sociomedical conditions like severe malnutrition and improving pneumonia etiology diagnostics will be key for better targeting interventions to improve childhood pneumonia outcomes.

Antibiotic treatment failure in children aged 1 to 59 months with World Health Organization-defined severe pneumonia in Malawi: A CPAP IMPACT trial secondary analysis

Antibiotic treatment failure in children aged 1 to 59 months with World Health Organization-defined severe pneumonia in Malawi: A CPAP IMPACT trial secondary analysis

Care-seeking patterns amongst suspected paediatric pneumonia deaths in rural Malawi.

Background: Pneumonia remains a leading cause of paediatric deaths. To understand contextual challenges in care pathways, we explored patterns in care-seeking amongst children who died of pneumonia in Malawi. Methods: We conducted a mixed-methods analysis of verbal autopsies (VA) amongst deaths in children aged 1-59 months from 10/2011 to 06/2016 in Mchinji district, Malawi. Suspected pneumonia deaths were defined as: 1. caregiver reported cough and fast breathing in the 2-weeks prior to death; or, 2. the caregiver specifically stated the child died of pneumonia; or 3. cause of death assigned as 'acute respiratory infection' using InterVA-4. Data were extracted from free-text narratives based on domains in the 'Pathways to Survival' framework, and described using proportions. Qualitative analysis used a framework approach, with pre-specified themes. Results: We analysed 171 suspected pneumonia deaths. In total, 86% of children were taken to a healthcare facility during their final illness episode, and 44% sought care more than once. Of children who went to hospital (n=119), 70% were admitted, and 25% received oxygen. Half of the children died within a healthcare setting (43% hospital, 5% health centre and 2% private clinics), 64 (37%) at home, and 22 (13%) in transit. Challenges in delayed care, transport and quality of care (including oxygen), were reported. Conclusions: Healthcare was frequently sought for children who died of suspected pneumonia, however several missed opportunities for care were seen. Sustained investment in timely appropriate care seeking, quick transportation to hospital and improved case management at all levels of the system is needed.

Care-seeking patterns amongst suspected paediatric pneumonia deaths in rural Malawi

Background: Pneumonia remains a leading cause of paediatric deaths. To understand contextual challenges in care pathways, we explored patterns in care-seeking amongst children who died of pneumonia in Malawi. Methods: We conducted a mixed-methods analysis of verbal autopsies (VA) amongst deaths in children aged 1-59 months from 10/2011 to 06/2016 in Mchinji district, Malawi. Suspected pneumonia deaths were defined as: 1. caregiver reported cough and fast breathing in the 2-weeks prior to death; or, 2. the caregiver specifically stated the child died of pneumonia; or 3. cause of death assigned as ‘acute respiratory infection’ using InterVA-4. Data were extracted from free-text narratives based on domains in the ‘Pathways to Survival’ framework, and described using proportions. Qualitative analysis used a framework approach, with pre-specified themes. Results: We analysed 171 suspected pneumonia deaths. In total, 86% of children were taken to a healthcare facility during their final illness episode, and 44% sought care more than once. Of children who went to hospital (n=119), 70% were admitted, and 25% received oxygen. Half of the children died within a healthcare setting (43% hospital, 5% health centre and 2% private clinics), 64 (37%) at home, and 22 (13%) in transit. Challenges in delayed care, transport and quality of care (including oxygen), were reported. Conclusions: Healthcare was frequently sought for children who died of suspected pneumonia, however several missed opportunities for care were seen. Sustained investment in timely appropriate care seeking, quick transportation to hospital and improved case management at all levels of the system is needed.

Care-seeking patterns amongst suspected paediatric pneumonia deaths in rural Malawi.

Background: Pneumonia remains a leading cause of paediatric deaths. To understand contextual challenges in care pathways, we explored patterns in care-seeking amongst children who died of pneumonia in Malawi. Methods: We conducted a mixed-methods analysis of verbal autopsies (VA) amongst deaths in children aged 1-59 months from 10/2011 to 06/2016 in Mchinji district, Malawi. Suspected pneumonia deaths were defined as: 1. caregiver reported cough and fast breathing in the 2-weeks prior to death; or, 2. the caregiver specifically stated the child died of pneumonia; or 3. cause of death assigned as 'acute respiratory infection' using InterVA-4. Data were extracted from free-text narratives based on domains in the 'Pathways to Survival' framework, and described using proportions. Qualitative analysis used a framework approach, with pre-specified themes. Results: We analysed 171 suspected pneumonia deaths. In total, 86% of children were taken to a healthcare facility during their final illness episode, and 44% sought care more than once. Of children who went to hospital (n=119), 70% were admitted, and 25% received oxygen. Half of the children died within a healthcare setting (43% hospital, 5% health centre and 2% private clinics), 64 (37%) at home, and 22 (13%) in transit. Challenges in delayed care, transport and quality of care (including oxygen), were reported. Conclusions: Healthcare was frequently sought for children who died of suspected pneumonia, however several missed opportunities for care were seen. Sustained investment in timely appropriate care seeking, quick transportation to hospital and improved case management at all levels of the system is needed.

Antimicrobial resistance in bacteria associated with childhood pneumonia in Malawi

Community acquired pneumonia (CAP) is a disease caused by an infection (by bacteria, viruses or fungi) that in cases of chronic infection lead to high mortality rates particularly in children. Pneumonia is the leading cause of death in children under the age of five worldwide with over 2 million deaths reported in 2016 by the World Health Organisation. Developing countries in sub Saharan Africa such as Malawi see some of the highest rates of the disease. CAP infections are responsible for 20% of deaths of new-borns in Malawi. Antibiotic resistance in disease causing organisms is of growing concern in countries like Malawi. We obtained bacterial isolates from blood samples taken from Malawian children, aged 18 -60 months, diagnosed with CAP. Streptococcus pneumonia is the primary pathogen in CAP but associated ESKAPE pathogens like Pseudomonas and Staphylococci spp. and Escherichia coli are of growing importance. These were the most common bacteria purified, isolated and characterised from these samples resulting in a unique culture collection. These pathogens have been screened for antimicrobial resistance with a variety of antibiotics to generate a resistance profile based on the minimal inhibitory concentrations of selected isolates using antibiotic susceptibility disks and by broth dilution method. Initial assessment shows current front-line therapies used by the Malawian ministry of health are ineffective in treating CAP. Our research aims to fully characterise these strains at the genetic level to better understand the mechanisms behind how antibiotic resistance develops to aid in combating this growing issue in countries like Malawi.

Bubble continuous positive airway pressure for children with high-risk conditions and severe pneumonia in Malawi: an open label, randomised, controlled trial

SummaryBackgroundPneumonia is the leading cause of death among children globally. Most pneumonia deaths in low-income and middle-income countries (LMICs) occur among children with HIV infection or exposure, severe malnutrition, or hypoxaemia despite antibiotics and oxygen. Non-invasive bubble continuous positive airway pressure (bCPAP) is considered a safe ventilation modality that might improve child pneumonia survival. bCPAP outcomes for high-risk African children with severe pneumonia are unknown. Since most child pneumonia hospitalisations in Africa occur in non-tertiary district hospitals without daily physician oversight, we aimed to examine whether bCPAP improves severe pneumonia mortality in such settings.MethodsThis open-label, randomised, controlled trial was done in the general paediatric ward of Salima District Hospital, Malawi. We enrolled children aged 1–59 months old with WHO-defined severe pneumonia and either HIV infection or exposure, severe malnutrition, or an oxygen saturation of less than 90%. Children were randomly assigned 1:1 to low-flow nasal cannula oxygen or nasal bCPAP. Non-physicians administered care; the primary outcome was hospital survival. Primary analyses were by intention-to-treat and interim and adverse events analyses per protocol. This trial is registered with ClinicalTrials.gov, number NCT02484183, and is closed.FindingsWe screened 1712 children for eligibility between June 23, 2015, and March 21, 2018. The data safety and monitoring board stopped the trial for futility after 644 of the intended 900 participants were enrolled. 323 children were randomly assigned to oxygen and 321 to bCPAP. 35 (11%) of 323 children who received oxygen died in hospital, as did 53 (17%) of 321 who received bCPAP (relative risk 1·52; 95% CI 1·02–2·27; p=0·036). 13 oxygen and 17 bCPAP patients lacked hospital outcomes and were considered lost to follow-up. Suspected adverse events related to treatment occurred in 11 (3%) of 321 children receiving bCPAP and 1 (<1%) of 323 children receiving oxygen. Four bCPAP and one oxygen group deaths were classified as probable aspiration episodes, one bCPAP death as probable pneumothorax, and six non-death bCPAP events included skin breakdown around the nares.InterpretationbCPAP treatment in a paediatric ward without daily physician supervision did not reduce hospital mortality among high-risk Malawian children with severe pneumonia, compared with oxygen. The use of bCPAP within certain patient populations and non-intensive care settings might carry risk that was not previously recognised. bCPAP in LMICs needs further evaluation before wider implementation for child pneumonia care.FundingBill & Melinda Gates Foundation, International AIDS Society, Health Empowering Humanity.

Validating a novel index (SWAT-Bp) to predict mortality risk of community-acquired pneumonia in Malawi.

Community-acquired pneumonia is a major cause of mortality worldwide. Early assessment and initiation of management improves outcomes. In higher-income countries, scores assist in predicting mortality from pneumonia. These have not been validated for use in most lower-income countries. To validate a new score, the SWAT-Bp score, in predicting mortality risk of clinical community-acquired pneumonia amongst hospital admissions at Queen Elizabeth Central Hospital, Blantyre, Malawi. The five variables constituting the SWAT-Bp score (male [S]ex, muscle [W]asting, non-[A]mbulatory, [T]emperature (>38°C or <35°C) and [B]lood [p]ressure (systolic<100 and/or diastolic<60)) were recorded for all patients with clinical presentation of a lower respiratory tract infection, presumed to be pneumonia, over four months (N=216). The sensitivity and specificity of the score were calculated to determine accuracy of predicting mortality risk. Median age was 35 years, HIV prevalence was 84.2% amongst known statuses, and mortality rate was 12.5%. Mortality for scores 0-5 was 0%, 8.5%, 12.7%, 19.0%, 28.6%, 100% respectively. Patients were stratified into three mortality risk groups dependent on their score. SWAT-Bp had moderate discriminatory power overall (AUROC 0.744). A SWAT-Bp score of ≥2 was 82% sensitive and 51% specific for predicting mortality, thereby assisting in identifying individuals with a lower mortality risk. In this validation cohort, the SWAT-Bp score has not performed as well as in the derivation cohort. However, it could potentially assist clinicians identifying low-risk patients, enabling rapid prioritisation of treatment in a low-resource setting, as it helps contribute towards individual patient risk stratification.

Bubble Continuous Positive Airway Pressure in the Treatment of Severe Pediatric Pneumonia in Malawi: A Cost-effectiveness Analysis

Bubble Continuous Positive Airway Pressure in the Treatment of Severe Pediatric Pneumonia in Malawi: A Cost-effectiveness Analysis

Bubble continuous positive airway pressure in the treatment of severe paediatric pneumonia in Malawi: a cost-effectiveness analysis

ObjectivesPneumonia is the largest infectious cause of death in children under 5 years globally, and limited resource settings bear an overwhelming proportion of this disease burden. Bubble continuous positive airway...

Early use of corticosteroids in infants with a clinical diagnosis of Pneumocystis jiroveci pneumonia in Malawi: a double-blind, randomised clinical trial

Background: Pneumocystis jiroveci pneumonia (PJP) is the most common opportunistic infection in infants with vertically acquired HIV infection and the most common cause of death in HIV-infected infants.Objectives: To determine whether early administration of adjuvant corticosteroids in addition to standard treatment reduces mortality in infants with vertically acquired HIV and clinically diagnosed PJP when co-infection with cytomegalovirus and other pathogens cannot be excluded.Methods: A double-blind placebo-controlled trial of adjuvant prednisolone treatment in HIV-exposed infants aged 2–6 months admitted to Queen Elizabeth Central Hospital, Blantyre who were diagnosed clinically with PJP was performed. All recruited infants were HIV-exposed, and the HIV status of the infant was confirmed by DNA-PCR. HIV-exposed and infected infants as well as HIV-exposed but non-infected infants were included in the study. The protocol provided for the addition of prednisolone to the treatment at 48 h if there was clinical deterioration or an independent indication for corticosteroid therapy in any patient not receiving it. Oral trimethoprim-sulfamethoxazole (TMP/SMX) therapy and full supportive treatment were provided according to established guidelines. Primary outcomes for all patients included survival to hospital discharge and 6-month post-discharge survival.Results: It was planned to enroll 200 patients but the trial was stopped early because of recruitment difficulties and a statistically significant result on interim analysis. Seventy-eight infants were enrolled between April 2012 and August 2014; 36 infants (46%) were randomised to receive corticosteroids plus standard treatment with TMP/SMX, and 42 infants (54%) received the standard treatment plus placebo. In an intention-to treat-analysis, the risk ratio of in-hospital mortality in the steroid group compared with the standard treatment plus placebo group was 0.53 [95% CI 0.29–0.97, p = 0.038]. The risk ratio of mortality at 6 months was 0.63 (95% CI 0.41–0.95, p = 0.029). Two children who received steroids developed bloody stools while in hospital.Conclusion: In infants with a clinical diagnosis of PJP, early use of steroids in addition to conventional TMP/SMX therapy significantly reduced mortality in hospital and 6 months after discharge.

Non-adherence to community oral-antibiotic treatment in children with fast-breathing pneumonia in Malawi- secondary analysis of a prospective cohort study.

BackgroundDespite significant progress, pneumonia is still the leading cause of infectious deaths in children under five years of age. Poor adherence to antibiotics has been associated with treatment failure in World Health Organisation (WHO) defined clinical pneumonia; therefore, improving adherence could improve outcomes in children with fast-breathing pneumonia. We examined clinical factors that may affect adherence to oral antibiotics in children in the community setting in Malawi.MethodsWe conducted a sub-analysis of a prospective cohort of children aged 2–59 months diagnosed by community health workers (CHW) in rural Malawi with WHO fast-breathing pneumonia. Clinical factors identified during CHW diagnosis were investigated using multivariate logistic regression for association with non-adherence, including concurrent diagnoses and treatments. Adherence was measured at both 80% and 100% completion of prescribed oral antibiotics.ResultsEight hundred thirty-four children were included in our analysis, of which 9.5% and 20.0% were non-adherent at 80% and 100% of treatment completion, respectively. A concurrent infectious diagnosis (OR: 1.76, 95% CI: 0.84–2.96/OR: 1.81, 95% CI: 1.21–2.71) and an illness duration of >24 h prior to diagnosis (OR: 2.14, 95% CI: 1.27–3.60/OR: 1.88, 95% CI: 1.29–2.73) had higher odds of non-adherence when measured at both 80% and 100%. Older age was associated with lower odds of non-adherence when measured at 80% (OR: 0.41, 95% CI: 0.21–0.78).ConclusionNon-adherence to oral antibiotics was not uncommon in this rural sub-Saharan African setting. As multiple diagnoses by the CHW and longer illness were important factors, this provides an opportunity for further investigation into targeted interventions and refinement of referral guidelines at the community level. Further research into the behavioural drivers of non-adherence within this setting is needed.

National hospital surveillance of childhood pneumonia in Malawi.

National hospital surveillance of childhood pneumonia in Malawi.

Lactate as a predictor of mortality in Malawian children with WHO-defined pneumonia

ObjectivesTo determine whether blood lactate measured at the time of presentation to hospital predicted outcome in children with pneumonia in Malawi, and to understand the factors associated with high blood...

Modelling the effect of malaria endemicity on spatial variations in childhood fever, diarrhoea and pneumonia in Malawi

Modelling the effect of malaria endemicity on spatial variations in childhood fever, diarrhoea and pneumonia in Malawi

Modelling the effect of malaria endemicity on spatial variations in childhood fever, diarrhoea and pneumonia in Malawi

BackgroundCo-morbidity with conditions such as fever, diarrhoea and pneumonia is a common phenomenon in tropical Africa. However, little is known about geographical overlaps in these illnesses. Spatial modelling may improve our understanding of the epidemiology of the diseases for efficient and cost-effective control.MethodsThis study assessed subdistrict-specific spatial associations of the three conditions (fever, diarrhoea and pneumonia) in relation to malaria endemicity. We used data from the 2000 Malawi demographic and health survey which captured the history of childhood morbidities 2 weeks prior to the survey date. The disease status of each child in each area was the outcome of interest and was modelled using a trivariate logistic regression model, and incorporated random effects to measure spatial correlation.ResultsThe risk of fever was positively associated with high and medium malaria endemicity levels relative to low endemicity level, while for diarrhoea and pneumonia we observed marginal positive association at high endemicity level relative to low endemicity level, controlling for confounding covariates and heterogeneity. A positive spatial correlation was found between fever and diarrhoea (r = 0.29); while weak associations were estimated between fever and pneumonia (r = 0.01); and between diarrhoea and pneumonia (r = 0.05). The proportion of structured spatial variation compared to unstructured variation was 0.67 (95% credible interval (CI): 0.31–0.91) for fever, 0.67 (95 % CI: 0.27–0.93) for diarrhoea, and 0.87 (95% CI: 0.62–0.96) for pneumonia.ConclusionThe analysis suggests some similarities in subdistrict-specific spatial variation of childhood morbidities of fever, diarrhoea and pneumonia, and might be a result of shared and overlapping risk factors, one of which is malaria endemicity.

Hidden risks for pneumonia in Malawi.

Domestic smoke exposure and early HIV infection are critical but unseen risk factors for pneumonia. This paper reviews how recent research in Malawi and elsewhere contributes to an understanding of the possible immunological mechanisms underlying these risks.