WHO Case Research Articles

Viral and atypical bacterial etiologies of severe acute respiratory infection (SARI) in Egyptian patients: epidemiological patterns and results from the sentinel surveillance study 2010–2014

Background Respiratory viral and atypical bacterial infections data in Egyptian patients are sparse. This study described the epidemiological pattern of viral and atypical bacteria as causes for severe acute respiratory infections (SARI) in hospitalized patients in Egypt. Patients and methods SARI surveillance was carried out at a Teaching University Hospital during the period 2010–2014. All hospitalized adults and pediatric patients meeting the WHO case definition criteria for SARI were enrolled. Nasopharyngeal/oropharyngeal swabs were collected and samples were tested using reverse transcription-PCR for influenza A, B, respiratory syncytial virus, human metapneumovirus, parainfluenza viruses 1, 2, 3, 4, adenovirus, human bocavirus, coronavirus, enterovirus, rhinovirus, and atypical bacteria (Mycoplasma spp., Chlamydia spp., and Legionella spp.). Results Overall, 1075/3207 (33.5%) cases had a viral etiology, and included 912 (84.4%) women and 163 (15.6%) men, with a mean age of 5.74±13.87 years. The highest rates were reported for respiratory syncytial virus (485 cases, 45.2%), parainfluenza virus (125, 11.6%), and adenovirus (105, 9.8%). Single viral etiology was reported in 901 (83.3%), while 174 (16.7%) cases had multiple etiologies. Children had a higher rate (981, 91.2%) compared with 94 (8.8%) cases in adults. Only three and one cases were positive for Mycoplasma spp. and Chlamydia spp. infections, respectively. Neither coronavirus nor Legionella spp. were detected. Conclusion Viral infections were encountered in one-third of hospitalized Egyptian adult and pediatric patients with SARI. Atypical bacteria had a minor role in SARI in our locality. Ongoing surveillance programs will better describe the epidemiology of SARI and will provide specific data to enable decision makers to take appropriate prevention measures.

Investigation of Crimean-Congo hemorrhagic Fever in Patients Admitted in Antani Hospital, Kabul, Afghanistan, 2017-2018.

Background:Crimean-Congo hemorrhagic fever (CCHF) is the most medically significant hemorrhagic fever. Afghanistan as an endemic region of CCHF has shown a rapidly growing incidence of the CCHF recently, but there is no data on the characteristic of the disease in this country, here we study the epidemiological, clinical, and paraclinical features of this disease in patients with CCHF, based on the collected data from the patients document records from March 2017 to January 2018 in the referral infectious diseases hospital of Afghanistan (Kabul Antani Hospital).Methods:A cross-sectional study in 120 patients admitted in Kabul ANTANI hospital was carried out from March 2017 to January 2018. All of the patients were included based on the standard case definitions by World Health Organization.Results:Among the 120 patients admitted to CCHF ward, 29 were confirmed by ELISA (18% IgM, 8% IgG+) and the reminders defined as “probable cases” according to WHO case definition. Case fatality rates were calculated as 15% and the overall mean ages were 35 years. The peak of the disease incidence occurred between August and July. Almost all patients reported fever, bleeding, and thrombocytopenia.Conclusions:Early detection plays an important role in patients' outcome. Considering that the most cases of the disease are associated with some contacts around Eid-Adha and death attributable to CCHF usually occur in the first 7 days of disease onset, educating population, and especially slaughters, gloves using by housewives during contacts with meat or animal products, and early detection and immediate treatment would have essential roles in primary and secondary prevention of CCHF. Hemorrhagic manifestations and low platelet count provide a clue to early detection of disease. Vaginal bleeding can be a sign of CCHF and needs immediate action.

Association between the clinical findings and chest radiographs in children with severe pneumonia aged 1 month to 5 years

Background: Pneumonia is the main cause of death among children under five years of age particularly in developing countries. According to the WHO, there are more than 15 million cases representing 7-13% of pneumonia cases annually which necessitate hospital admission due to their severity. There is paucity of data regarding the clinical spectrum and the epidemiology of severe pneumonia from eastern part of Nepal. It is important to understand the clinical spectrum and the epidemiology of severe pneumonia at local level to better define problem and to draw inferences for management and policy formulation.
 Material and Methods: A hospital based retrospective observational study conducted at Department of Pediatrics and Neonatology, Nobel Medical College and Teaching Hospital, Biratnagar, Nepal. One hundred and forty four cases with a diagnosis of severe pneumonia were studied over a period of one year. All the cases from 1 month to 5 years of age fulfilling the standard WHO case definition of severe pneumonia were included in the study. A pre-designed semi-structured questionnaire was used to obtain the clinical profile and investigations.
 Results: A total of 144 cases were studied and analyzed. The age range was from 1 month to 5 years. The mean age of the cases was 13.56 months. Majority of the cases belonged to age group of 1-6 months 40.27% (n=58). There was a male preponderance in our study comprising 58.3% (n=84) of males and 41.7% (n=60) of females. Fever and cough were the most common symptoms present in all cases, fever being present in 95.8% (n=136) cases and cough was present in 98.6% (n=142) cases. The most common radiological finding in our study was bronchopneumonia in 27.8% (n=40) cases followed by lobar pneumonia in 24.3% (n=35) cases and interstitial pneumonia in 18.8% (n=27) cases. Complications were present in 6.9% (n=10) cases and 22.2% (n=32) of the cases had no radiological abnormalities. Among the studied symptoms and signs of severe pneumonia, hurried breathing (p<0.001), wheeze (p=0.016), refusal of feeds (p=0.001), altered sensorium (p=0.006) and previous history of acute respiratory infections showed significant association with radiological abnormalities.
 Conclusion: Children of severe pneumonia presenting with fast breathing, wheeze, altered sensorium, refusal of feeding and past history of acute respiratory infections showed significant association with abnormal chest radiographs.

431. Enhanced Malaria Surveillance in Greece, 2009–2017

BackgroundDuring 2009–2012, sporadic locally acquired (LA) P. vivax malaria cases and clusters were reported in Greece, a malaria-free country. Evrotas, an agricultural area in southern Greece with large migrant population from the Indian sub-continent, was the most affected area. In 2011–2017, we implemented enhanced malaria surveillance to timely detect and treat cases.MethodsWe applied the WHO case definitions for imported, LA, and introduced cases. We raised awareness among clinicians and investigated all reported cases. We actively screened for fever (i) the local population in the place of exposure of LA cases, and (ii) weekly, the migrant population in Evrotas, from April to November every year (active case detection, ACD). We distributed rapid diagnostic tests (RDTs) to enhance local diagnostic capacity. In 2015–2017, we established enhanced malaria surveillance in refugee/migrant hosting centers (RMHC).ResultsIn 2009–2017, 662 malaria cases were reported (67% P. vivax); 561 were imported, including 442 (79%) in migrants from endemic countries and 119 in travelers. The median annual number of imported cases in migrants increased from 32 (range 12–64) in 2009–2014 to 85 (range 65–91) in 2015–2017. In 2015–2017, 23% (n = 55) of all cases in migrants were detected in RMHC or points of entry. In 2011 and 2012, 42 and 20 LA P. vivax cases were reported in Greece, including 36 and 10 cases in Evrotas, respectively, while in 2013–2017, the annual median number of LA P. vivax cases decreased to 6 (range 0–8); all were introduced cases. RDTs contributed to the diagnosis in almost 100% of cases in Evrotas and in 96% of cases in RMHC or points of entry. In Evrotas, during ACD, time from disease onset to diagnosis decreased from 6 days in 2011 to 0.5 days in 2017.ConclusionFollowing the 2011–2012 peak of LA cases and the implementation of PH measures, the number of LA cases decreased substantially, despite the increased migrant influx. However, the presence of local competent vectors, combined with cases from malaria-endemic countries, heightens the risk of re-introducing malaria in receptive malaria-free areas. Although resource demanding, enhanced malaria surveillance contributed to minimizing the transmission risk and should be continued.Disclosures All authors: No reported disclosures.

Community-based, prospective cohort study evaluating susceptibility to measles during the first year of life among infants in India

Background: Measles is a significant public health problem in India, despite infant vaccination at 9 months of age since 1985. The age of 9 months was chosen to balance the disappearance of maternal (transplacental) antibodies and ability of infants to mount an immune response. However, the duration and quality of transplacental protection has not been studied in the present era, wherein majority of mothers have antibodies acquired through vaccination rather than natural infection. This community-based, prospective study was undertaken to determine measles susceptibility in infants followed from birth to 12 months of age, in 30 anganwadi clusters in Chandigarh, India. Methods & Materials: Using systematic random sampling, 420 infants and mothers were recruited at birth. The infants were followed up at 3, 6 and 9 months (pre-vaccination). At each visit, history of measles (WHO case definition) was inquired about and blood drawn for quantitative estimation of anti-measles IgG antibodies using ELISA kits. The proportion of susceptible infants at each time point and the ratio of maternal:infant antibody level at birth were calculated. Results: A total of 305 mothers and 305 infants completed the study protocol. Of these, 90% mothers had protective levels of antibodies (defined > 12mIU/ml), 7% were unprotected and 3% had borderline status. The proportion of protected, unprotected and borderline infants were 92%, 6% and 2% respectively. The proportion of infants that was susceptible to measles at 3, 6 and 9 months was 67%, 97%, and 99% respectively. Only one infant had clinical and laboratory confirmed measles prior to 9 months of age. At birth, only 54 (17.7%) pairs had mother:infant antibody levels in the ratio of 1.0 + 0.1. The remainder had either higher (n = 111, 36.4%) or lower (n = 140, 45.9%) antibody ratios. Conclusion: These data confirm that the majority of Indian infants are susceptible to measles well before the expected age of 9 months. The inconsistent maternal: infant antibody ratio suggests that transplacental antibody transfer cannot always be relied on for infant protection. Taken together, this study confirms an urgent need to lower the age of infant measles vaccination in India.

Diversity of rotavirus strains circulating in children under five years of age who presented with acute gastroenteritis before and after rotavirus vaccine introduction, University Teaching Hospital, Lusaka, Zambia, 2008–2015

BackgroundFollowing the introduction of rotavirus vaccine into the routine immunization schedule, the burden of rotavirus disease has significantly reduced in Zambia. Although rotavirus vaccines appear to confer good cross-protection against both vaccine and non-vaccine strains, concerns about strain replacement following vaccine implementation remain. We describe the diversity of the circulating rotavirus strains before and after the Rotarix® vaccine was introduced in Lusaka from January 2012. MethodsUnder five children were enrolled through active surveillance at University Teaching Hospital using a standardized WHO case investigation form. Stool samples were collected from children who presented with ≥3 loose stool in 24 h and were admitted to the hospital for acute gastroenteritis as a primary illness. Samples were tested for group A rotavirus antigen enzyme-linked immunosorbent assay. Randomly selected rotavirus positive samples were analysed by reverse transcription polymerase chain reaction for G and P genotyping and and Nucleotide sequencing was used to confirm some mixed infections. ResultsA total of 4150 cases were enrolled and stool samples were collected from 4066 (98%) children between 2008 and 2011, before the vaccine was introduced. Rotavirus antigen was detected in 1561/4066 (38%). After vaccine introduction (2012 to 2015), 3168 cases were enrolled, 3092 (98%) samples were collected, and 977/3092 (32%) were positive for rotavirus. The most common G and P genotype combinations before vaccine introduction were G1P[8] (49%) in 2008; G12P[6] (24%) and G9P[8] (22%) in 2009; mixed rotavirus infections (32%) and G9P[8] (20%) in 2010, and G1P[6] (46%), G9P[6] (16%) and mixed infections (20%) in 2011. The predominant strains after vaccine introduction were G1P[8] (25%), G2P[4] (28%) and G2P[6] (23%) in 2012; G2P[4] (36%) and G2P[6] (44%) in 2013; G1P[8] (43%), G2P[4] (9%), and G2P[6] (24%) in 2014, while G2P[4] (54%) and G2P[6] (20%) continued to circulate in 2015. ConclusionThese continual changes in the predominant strains suggest natural secular variation in circulating rotavirus strains post-vaccine introduction. These findings highlight the need for ongoing surveillance to continue monitoring how vaccine use affects strain evolution over a longer period of time and assess any normal seasonal fluctuations of the rotavirus strains.

Abstract PD-011: RISK FACTORS FOR SEVERE DENGUE: RETROSPECTIVE OBSERVATIONAL STUDY FROM A PICU IN SOUTHERN INDIA

Aims & Objectives: To describe clinical pattern of dengue fever (DF) and find out risk factors for severe dengue. Methods A retrospective study covering calendar year 2017 was done in a tertiary care centre in south India. Case records of children (1 month-13 years) admitted to pediatric emergency with suspected DF were screened and data analyzed. Results In 2017, 160 cases were screened of which 121(75.6%) were dengue proven (revised WHO case definition) and 22(13.8%) had probable dengue. Cases were classified as DF (9.1%), dengue fever with warning signs (66.4%) and severe dengue (24.5%). Median age was 8 years (IQR 4.8–10 years) and 54.5% were males. Fever (100%), vomiting (76.2%) and pain abdomen (54.3%) were the most common presenting symptoms. Hepatomegaly (64.3%) and thrombocytopenia (86.5%) were the commonest sign and investigation findings. There were 2 deaths (0.01%) and shock (23.8%) and massive pleural effusion (14.7%) were most frequent complications (Figure). Demographic parameters, symptoms, signs and investigations were studied as possible risk factors for severity. Female sex was associated with severe dengue (OR=1.6; 95% C.I. [0.74–3.45]). Among symptoms, bleeding tendency had significant association with severe dengue (OR=5.7; 95% C.I. [2.16–15.23]). Hepatomegaly (OR=3.5; 95% C.I. [1.32–9.0]) and severe thrombocytopenia (OR=3.63; 95% C.I. [1.5–8.8]) had significant association with severe dengue among signs and investigations (Table).Conclusions Studies on pattern of DF from different regions should help in mapping global trends. The key to management in severe dengue is meticulous monitoring and supportive care. Identification of risk factors could streamline specific protocols for actionable outcomes in Pediatric Intensive Care Units.

Evaluation of Multi Drug Resistant Tuberculosis Surveillance System, Yemen

Background: Developing Multi Drug-resistant TB (MDR-TB) is a threat facing the National Tuberculosis Control Program (NTCP) in Yemen. Four sentinel Surveillance sites were established in 2014 to monitor the situation and guide control. Objective: Assess the performance of MDR-TB Surveillance and provide recommendations. Methods: We use the Center of Diseases Control (CDC) updated guideline for evaluating public health surveillance systems. In-depth interviews were conducted with six NTCP and 12 central and regional MDR-TB Centers managers/staff. We used 5-Likert scale to assess performance by attributes (e.g. usefulness, simplicity, flexibility) according to the following scoring system: Poor (80). NTCP-modified WHO case definitions for treatment outcome was used where treatment success defined as completing treatment according to protocol with at least five consecutive negative smears from samples collected at least 30 days apart in the final 12 months of treatment. Results: MDR-TB Surveillance System achieved good performance in usefulness, acceptability and data quality compared to average score in flexibility and simplicity; and poor score in stability. Detection rate was 25% in 2014 and increased to 32% in 2016 compared to the target of 40%. Enrollment decreased from 92% in 2014 to 69% in 2016 compared to 100% target. Treatment success reached 70% in 2016. Conclusions: MDR-TB surveillance system was found to be useful, but more efforts is needed to improve stability through ensuring constant power supply for the laboratory to be able to perform drug sensitivity with gradual replacement of donor’s funds by government. Although detection rate showed some increase in 2016, enrollment decreased due to unavailability of MDR-TB drugs and long waiting list. Scaling-up of MDR-TB services and removing access barriers are crucial to increase detection rate together with enhancing treatment availability to increase enrollment are recommended. Adapting WHO shorter regimen and inpatients management when needed will help to improve treatment success.

Drug Resistant Tuberculosis: An Emerging Public Health Threat in Yemen, 2014-2016

Background: Drug-resistant tuberculosis (DR-TB) is a serious obstacle for successful TB control. The 2010–2011 Yemen DR-TB Survey showed an overall Multi DR-TB (MDR-TB) prevalence of 2.9% that was 1.4% in newly- and 14.4% in previously- treated patients. DR-TB Surveillance system was introduced in Yemen in December 2013 to improve detection and management of DR-TB. Objective: To describe the pattern, drug sensitivity and treatment outcome of DR-TB. Methods: Data on DR-TB cases from 2014 to 2016 was obtained from National Tuberculosis Control Program (NTCP). The NTCP modified WHO case definitions for treatment outcome was used where treatment success defined as completing treatment according to program protocol with at least five consecutive negative smears from samples collected at least 30 days apart in the final 12 months of treatment. Results: Out of 32,528 TB patients diagnosed during 2014 -2016, 115 (4/1000) were DR-TB. The highest number was reported from Aden (40%) and lowest from Taiz 12%; 59% among males; and 67% among most productive years (24-45 years). Furthermore, 97% was among previously treated TB patients and 3% was positive for HIV. MDR-TB confirmed in 68% and Rifampicin Resistance (RR-TB) in 31%. The treatment success rate was 70% and death rates was 15%. Detection and enrollment rates were 27% and 80%. Conclusions: Despite NTCP efforts to respond to the challenge of DR-TB in Yemen, scaling-up of DR-TB services and removing the access barriers are crucial to increase the detection rate. Comprehensive strategies targeting priority population especially those enhancing treatment availability need to be implemented to increase enrollment. More intensive efforts to better manage MDR/RR-TB through adapting WHO shorter recommended regimen and inpatients management for those requires hospitalization will help to improve the treatment success and minimize further emergence of totally drug-resistant TB cases.

Diphtheria Outbreak in Bait Hulboob, Wasman Villages, Ibb governorate - Yemen, September 2017

Background: Remerging of diphtheria outbreaks have been associated with wars and threaten the health of children and adult. On 25th of September 2017 surveillance officer of Ibb governorate received a notification from surveillance coordinator of Alsaddah district about suspected deaths due to diphtheria. A team from Ibb surveillance office was sent to investigate on 26/09/2017. Objective: To verify the existence of an outbreak, describe its epidemiology and recommend preventive and control measures. Methods: A descriptive study was done. WHO case definition was used. A line list was created, active case finding, and clinical diagnosis were performed. Records of surveillance and vaccinations programs were reviewed. Data was entered and analyzed using Excel program. Descriptive statistics were performed. Results: A total of 63 cases were identified. The first case was in Epi week 34, the highest peak with 32 cases were in week 38. The index case was 17 years old male from Bait Hulboob village. The majority of cases 47 (74%), were from that village. Almost three quarters of cases 45 (71%) were males, 22 cases (35%) among children aged from 5-10years. 43 cases (68%) was unvaccinated and the rest was partially vaccinated. All presented with pseudo membrane, 42 cases (67%) with sore throat and 10 (16%) with bull neck. The attack rate was 15/1000. 4 cases died (the case fatality rate was 6%). Conclusions: Diphtheria outbreak was clinically confirmed. Low vaccination coverage. Vaccination campaign for population and provision of Diphtheria antitoxin for patients are urgently recommended. Immunization and health education should be emphasized by governorate authority.

Cholera Outbreak Investigation in Sawan Area, Shuaub District, Sana'a Capital City, Yemen, October 2016

Background: Diarrheal diseases are the second leading cause of death among children <5, 1 in 9 children die from diarrhea infection worldwide. The majority (88%) of these deaths are associated with unsafe water, inappropriate sanitation and lack of hygiene. Vibrio Cholerae bacterium can cause extremely virulent diarrhea. On October 2016 an outbreak of watery diarrhea occurred among a family in Al-Nasser St. Sawan area, Shuaub district, Sana'a capital city, Yemen. Objective: An outbreak investigation was done to confirm the outbreak, to identify the source, risk factors and recommend control measures. Methods: A descriptive and analytical studies were conducted. Active search of cases and control was performed. WHO case definition of cholera during epidemic was adopted. Stool samples were taken and sent to the public health central lab. for confirmation. The data was entered and analyzed by Epi Info 7.2 and Excel sheet were performed. Chi square and odds ratio were calculated. Results: Out of 28 cases, 15 (54%) were females. The index case, a 65 years-old female, was identified on October 3rd. The peak of cases was on October 8th, 2016 (46%). The attack rate was 3/1000 population with no case fatality. Children < 5 (24%) and those 5-10 years (24%) were mostly affected. Out of 18 stool samples, 11 Vibrio cholera serotype 01 Eltor-ogawa was isolated (61%). The identified risk factors were: untreated water OR=10.7, (CI: 3.95-29.1) grape OR=4 (CI: 1.5-10.8), and porridge OR=3.1 (CI: 1.4-7.5). Conclusions: Cholera outbreak was confirmed. Most cases were children up to ten years old. There was association between drinking water, eating raw vegetables and cholera infection. Boiling or chlorination of water and hand washing were recommended to control the outbreak

Incidence and degree of hypoxaemia in Malawian infants under 2 months of age presenting to district hospitals and its correlation with mortality: a retrospective analysis

Abstract Background Pneumonia is a leading cause of death in Malawian infants under 2 months of age. Consensus defines hypoxaemia in infants as a peripheral capillary oxygen saturation (SpO 2 ) of less than 90%. We aimed to estimate the incidence and degree of hypoxaemia and its correlation with mortality in infants younger than 2 months presenting to district hospitals in Malawi. Methods We retrospectively analysed a child pneumonia surveillance dataset prospectively collected during routine care at seven hospitals in Malawi between 2011 and 2014. Infants aged 0–2 months with pneumonia according to 2012 WHO case management guidelines were included. We used logistic regression to determine correlation between degree of hypoxaemia and in-hospital death. Findings 1810 infant pneumonia admissions were analysed. The case fatality rate was 3·6% (n=65). SpO 2 could not be measured in 8·5% (n=154) of patients. Median SpO 2 was 96% (IQR 91–98). Infants for whom SpO2 measurement was successful versus unsuccessful had a similar prevalence of chest indrawing (85·6% vs 79·2%) and WHO danger signs (68·4% vs 61·0%; p=0·064), and the distribution of girls (40·9% vs 39·6%) was also comparable. Compared with infants with an SpO 2 of 93–100% (n=1160), infants with an SpO 2 of 90–92% (n=187) or 2 was not measurable (n=154) had a greatly increased adjusted odds of death compared with infants with a SpO2 of 93–100% (aOR 17·5, 95% CI 7·5–40·8). Interpretation The case definition of hypoxaemia in infants less than 2 months of age warrants re-evaluation. Infants with an SpO 2 of 90–92% have a higher odds of death than those with a SpO 2 of 93–100%. Infants for whom SpO 2 could not be measured, despite having similar demographic and physical examination findings, had a higher odds ratio for death than any other observed group. Interestingly, these infants had a lower rate of WHO danger signs, but probably had severe disease such as shock with diminished peripheral perfusion resulting in inability to measure SpO 2 . WHO danger signs may not adequately capture such physiological derangements. The inability to measure pulse oximetry is clinically meaningful in our setting. Implementation of compulsory SpO 2 measurement could result in improved referral rates and recognition of severe disease in infants younger than 2 months of age with pneumonia. Funding None.

Neurobehavioural symptoms and acute pesticide poisoning: a cross-sectional study among male pesticide applicators selected from three commercial farming systems in Ethiopia

ObjectiveTo estimate prevalence of acute pesticide poisoning (APP) and its association with neurobehavioural symptoms in Ethiopian pesticide applicators.MethodsWe performed a cross-sectional survey among 256 pesticide applicators from small-scale irrigated farms,...

Early-life exposure to indoor air pollution or tobacco smoke and lower respiratory tract illness and wheezing in African infants: a longitudinal birth cohort study

SummaryBackgroundIndoor air pollution (IAP) and environmental tobacco smoke (ETS) are associated with lower respiratory tract illness (LRTI) or wheezing in children. However, the effect of the timing of these exposures, specifically antenatal versus postnatal, and of alternate fuel sources such as the increasingly used volatile organic compounds have not been well studied. We longitudinally investigated the effect of antenatal or postnatal IAP and ETS on LRTI or wheezing prevalence and severity in African infants.MethodsMother and infant pairs enrolled over a 3-year period in a birth cohort study in two centres in Paarl, South Africa, were followed for the first year of life for LRTI or wheezing illness. We measured exposure to IAP (particulate matter, nitrogen dioxide, sulphur dioxide, carbon monoxide, and volatile organic compounds benzene and toluene) using devices placed in homes, antenatally and postnatally. We measured ETS longitudinally by maternal self-report and by urine cotinine measures. Study staff trained in recognition of LRTI or wheeze documented all episodes, which were categorised according to WHO case definition criteria. We used multivariate logistic and Poisson regressions to explore associations.FindingsBetween March 1, 2012, and March 31, 2015, we enrolled 1137 mothers with 1143 livebirths. Of 1065 infants who attended at least one study visit, 524 episodes of LRTI occurred after discharge with a wheezing prevalence of 0·23 (95% CI 0·21–0·26) episodes per child year. Exposures associated with LRTI were antenatal maternal smoking (incidence rate ratio 1·62, 95% CI 1·14–2·30; p=0·004) or particulate matter (1·43, 1·06–1·95; p=0·008). Subanalyses of LRTI requiring hospitalisation (n=137) and supplemental oxygen (n=69) found antenatal toluene significantly increased the risk of LRTI-associated hospitalisation (odds ratio 5·13, 95% CI 1·43–18·36; p=0·012) and need for supplemental oxygen (13·21, 1·96–89·16; p=0·008). Wheezing illness was associated with both antenatal (incidence rate ratio 2·09, 95% CI 1·54–2·84; p<0·0001) and postnatal (1·27, 95% CI 1·03–1·56; p=0·024) maternal smoking. Antenatally, wheezing was associated with maternal passive smoke exposure (1·70, 1·25–2·31; p=0·001) and, postnatally, with any household member smoking (1·55, 1·17 −2·06; p=0·002).InterpretationAntenatal exposures were the predominant risk factors associated with LRTI or wheezing illness. Toluene was a novel exposure associated with severe LRTI. Urgent and effective interventions focusing on antenatal environmental factors are required, including smoking cessation programmes targeting women of childbearing age pre-conception and pregnant women.FundingBill & Melinda Gates Foundation, Discovery Foundation, South African Thoracic Society AstraZeneca Respiratory Fellowship, Medical Research Council South Africa, National Research Foundation South Africa, and CIDRI Clinical Fellowship.

DENGUE RAPID DIAGNOSTIC TESTS;

Objectives: To determine the point of care role of dengue IgA and Dengue IgM/ IgG rapid diagnostic tests (RDTs) in a tertiary care setting in terms of day of onset of illness atpresentation and frequency of positive RDTs in dengue hemorrhagic fever (DHF) and dengueshock syndrome (DSS). Study Design: Cross-sectional study. Setting: Abbasi ShaheedHospital, Karachi. Period: August-2014 to January-2016. Method: Patients aged 13years andabove with acute febrile illness, fulfilling the WHO case definition criteria of probable DF andDHF were included. Two immunochromatograpic (ICT) based RDTs, Assure dengue IgA andPanbio Dengue Duo Cassette (IgM / IgG) were used. Dengue IgA was employed in all patientsfrom day 2 of illness whereas IgM / IgG was employed after day 4 of onset of fever. Result:Among 174 probable cases, 108 (62%) presented between 2 – 5 days of onset of fever, amongwhom 87 (80.5%) were found to be dengue IgA positive. Sixty-nine (39.65%) patients had DHF,among whom 97.1% were seropositive for IgA. Of 118 patients presented after 4 days of onsetof illness, 59.3% were positive by IgM / IgG rapid assay. Conclusion: Considering the higherfrequency of secondary dengue and DHF in dengue endemic-hyperendemic regions, IgAbased ICT might be a helpful diagnostic assay for early diagnosis of dengue infection.

Neurological Sequelae in Acute Encephalitis Syndrome one month post discharge from the hospital in the Children Aged 1-14 years

Introduction Encephalitis is a complex clinical syndrome of the central nervous system (CNS) associated with fatal outcome or severe permanent damage including cognitive impairment, behavioral impairment and epileptic seizures. It is important to understand the clinical spectrum and outcome of acute encephalitis syndrome(AES) at local level to better define problem and to draw inferences for management and policy formulation.Material and Methods: This study was a hospital based observational, longitudinal and descriptive study conducted at Department of Pediatrics; Nobel Medical College Teaching Hospital, Biratnagar. Seventy cases with a diagnosis of AES (irrespective of the underlying etiology), were studied over a period of one year. All cases from 1 to 14 years of age fulfilling the standard WHO case definition of AES were included in the study. A pre-designed semistructured questionnaire was being used to obtain the clinical profile and investigations. The cases were followed after one month post discharge from the hospital and the outcomes were recorded.Results: On follow up of the cases at the end of 1 month, 35 (50.7%) cases were found to have complete cure and were labelled as cured. Neurological sequelae were seen in 8(11.6%) cases and were labeled as not cured. Total death was documented in 26(37.7%) of the cases.Conclusion: Despite of early diagnosis and aggressive treatment neurological sequelae is not uncommon in AES. So, regular follow up and early rehabilitative efforts should be instituted for all cases of AES post discharge from the hospital.Journal of Nobel Medical College Vol.5(2) 2016; 43-46

Ebola virus disease in children: towards a better clinical picture and improved management.

Ebola virus disease in children: towards a better clinical picture and improved management.

Revision of Meningitis Surveillance System in Jordan during 2001 and 2014 Years

Background: Since 2002 a specific categorization of meningitis cases was initiated in Directorate of Communicable Diseases (DCD). Analyzing data reveals severe underreporting of meningitis cases from some reporting sites (up to zero), therefore it is important to conduct a study that measures sensitivity of the system (data quality, predictive value positive and representativeness). Objective: To determine proportion of cases that fit adopted case definition (by WHO) and to determine completeness of data received by DCD from hospitals. Methodology: The researcher adopted a case definition based on WHO criteria for suspected and probable cases and applied it to viral meningitis in order to determine what proportion of cases fits case definition. To calculate the sensitivity of the surveillance system, clinical records of all meningitis cases admitted to four major hospitals from different health sectors were reviewed during the study period and compared to reported cases to the DDC. Results: The researcher identified and evaluated all meningitis cases in 2001 and 2014 years, 7% fit the suspected WHO case definition for viral meningitis in ages <2 years and 1.3% fit the probable. For ages ≥2 years 76% fit the suspected cases and 26.8% fit probable. The sensitivity for all types for hospital A=10%, hospital B=50%, hospital C=63% and hospital D=99%. Hospital A is the largest referral hospital in Jordan. Conclusions: Non-standardized case definition by clinicians plagues the meningitis surveillance system. Targeted efforts to strengthen the system should be adopted by the Ministry of Health (National Clinical Guidelines, Active System Versus Passive).

Incidence of childhood pneumonia: facility-based surveillance estimate compared to measured incidence in a South African birth cohort study

BackgroundPneumonia is the leading cause of childhood mortality and a major contributor to childhood morbidity, but accurate measurement of pneumonia incidence is challenging. We compared pneumonia incidence using a facility-based...

Is dengue virus neurotropic?

Dengue viral infection is on the rise in tropical urban and semi-urban parts of the world. WHO fact sheet- N°117 updated in May 2015 estimates 390 million dengue infections per year and that 3900 million people, in 128 countries, are at risk. The WHO case definition of severe dengue includes organ impairment, but does not describe neurological manifestations as a separate entity. Earliest reports on neurological manifestations came from Indonesia 35 to 40 years back. Abundant literature is available on diverse neurological manifestations in dengue from India and other parts of the world. Encephalopathy, aseptic meningitis, papilledema, stroke, intracranial and sub- arachnoid haemorrhage (ICH/ SAH), Acute Disseminated Encephalomyelitis (ADEM), opsoclonus- myoclonus syndrome, myelitis cranial nerve palsies, polyneuropathies, Guillain-Barre syndrome (GBS), polymyositis, and hypokalemic paralysis are all reported. Long-term sequelae recorded are Parkinsonism, dystonias, cognitive changes, behavioural disorders, depression, amnesia, dementia and psychosis. The neurological manifestations in dengue can be grouped into 3 categories – (I) those related to the neuro-myotropic effects of the virus (II) those related to the systemic complications of dengue infection like vascular leakage, hemoconcentration, haemorrhage and dyselectrolytemia; and (III) Post- infectious manifestations like ADEM, encephalomyelitis, myelitis, optic neuritis, GBS and mono and polyneuropathies. Dengue virus belongs to the flaviviridae family, several members of which have proven neurotropism and propensity for the sub- cortical nucleii. CNS invasion, either through neurotropism or vascular leakage is supported by inconsistent evidence including animal experiments. Presence of virus and IgM- dengue in the CSF of some encephalopathy cases suggests capability, but not invariability of CNS invasion. Glycosylation of the envelope protein, increased inflammatory cytokines disrupting the blood brain barrier (BBB) allowing free virus access to the CNS and non-specific cellular virus attachment factors are all implicated. Some authors recommend a high index of suspicion for dengue in CNS infections occurring in endemic countries. Three tetravalent live-attenuated vaccines are under development in phase II and phase III clinical trials, and 3 other vaccine candidates (based on subunit, DNA and purified inactivated virus platforms) are at earlier stages of clinical development. Their immunogenicity may be implicated in neurological manifestations in the future.