Sociodemographic determinants of COVID-19 vaccination in adolescents in Stockholm, Sweden.

INTRODUCTION: Limited data exists on sociodemographic differences in vaccination coverage against COVID-19 among adolescents. This study investigated the association of sociodemographic factors and vaccination coverage of adolescents aged 12 to 17 years over the period of the general vaccination recommendation in Stockholm County, Sweden. METHOD: We conducted a population-based retrospective cross-sectional study of vaccine uptake of at least one dose of a COVID-19 vaccine up until 31 October 2022. We analysed vaccination coverage by sex, age group, underlying medical conditions, household socioeconomic factors, and vaccination status among adults in the household, using stratified analyses and multivariable modified Poisson regression models. RESULTS: The study cohort consisted of 166,634 adolescents out of which 70.3 % (n = 117,185) received at least one dose of a COVID-19 vaccine. In the fully adjusted model, the strongest predictor for not being vaccinated was if all adults in the household were unvaccinated (adjusted relative risk, aRR, 0.11, 95 % CI 0.10-0.12). Lower household education level and having both parents born outside Sweden were similarly negatively associated with vaccination coverage among adolescents. No association was observed between vaccination coverage and being an adolescent with an underlying medical condition (aRR 1.00, 95 % CI 0.99-1.02). CONCLUSION: Our results emphasise the necessity to address sociodemographic disparities and to engage adolescents at risk through targeted measures with particular emphasis in low-vaccination households in addition to households with lower education and non-Swedish origins in future vaccination program strategies.

Exploring the determinants of under-five mortality and morbidity from infectious diseases in Cambodia-a traditional and machine learning approach.

Cambodia has made progress in reducing the under-five mortality rate and burden of infectious diseases among children over the last decades. However the determinants of child mortality and morbidity in Cambodia is not well understood, and no recent analysis has been conducted to investigate possible determinants. We applied a multivariable logistical regression model and a conditional random forest to explore possible determinants of under-five mortality and under-five child morbidity from infectious diseases using the most recent Demographic Health Survey in 2021-2022. Our findings show that the majority (58%) of under-five deaths occurred during the neonatal period. Contraceptive use of the mother led to lower odds of under-five mortality (0.51 [95% CI 0.32-0.80], p-value 0.003), while being born fourth or later was associated with increased odds (3.25 [95% CI 1.09-9.66], p-value 0.034). Improved household water source and higher household wealth quintile was associated with lower odds of infectious disease while living in the Great Lake or Coastal region led to increased odds respectively. The odds ratios were consistent with the results from the conditional random forest. The study showcases how closely related child mortality and morbidity due to infectious disease are to broader social development in Cambodia and the importance of accelerating progress in many sectors to end preventable child mortality and morbidity.

Cooling during transportation of newborns with hypoxic ischemic encephalopathy using phase change material mattresses in low-resource settings: a randomized controlled trial in Hanoi, Vietnam.

OBJECTIVE: To determine the effectiveness of phase-change-material mattress (PCM) during transportation of newborns with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN: Randomized controlled trial of newborns with HIE from June 2016 to December 2019. Patients were randomized to transport with PCM or without PCM (control) when transferred to a cooling center in northern Vietnam. Primary outcome measure was mortality rate, secondary outcomes including temperature control and adverse effects. RESULT: Fifty-Two patients in PCM-group and 61 in control group. Median rectal temperature upon arrival was 34.5 °C (IQR 33.5-34.8) in PCM-group and 35.1 °C (IQR 34.5-35.9) in control group (p = 0.023). Median time from birth to reach target temperature was 5.0 ± 1.4 h and 5.5 ± 1.2 h in the respective groups (p = 0.065). 81% of those transported with PCM versus 62% of infants transported without (p = 0.049) had reached target temperature within the 6-h timeframe. There was no record of overcooling (< 32 °C) in any of the groups. The was no difference in mortality rate between the two groups (33% and 34% respectively (p > 0.05)). CONCLUSION: Phase-change-material can be used as a safe and effective cooling method during transportation of newborns with HIE in low-resource settings. TRIAL REGISTRATION: The study was retro-prospectively registered in Clinical Trials (04/05/2022, NCT05361473).

Enablers and barriers to implementing cholera interventions in Nigeria: a community-based system dynamics approach.

Nigeria accounts for a substantial cholera burden globally, particularly in its northeast region, where insurgency is persistent and widespread. We used participatory group model building workshops to explore enablers and barriers to implementing known cholera interventions, including water, sanitation and hygiene, surveillance and laboratory, case management, community engagement, oral cholera vaccine, and leadership and coordination, as well as exploring leverage points for interventions and collaboration. The study engaged key cholera stakeholders in the northeastern States of Adamawa and Bauchi, as well as national stakeholders in Abuja. Adamawa and Bauchi States' group modes building participants comprised 49 community members and 43 healthcare providers, while the 23 national participants comprised government ministry, department and agency staff, and development partners. Data were analysed thematically and validated via consultation with selected participants. The study identified four overarching themes regarding the enablers and barriers to implementing cholera interventions: (1) political will, (2) health system resources and structures, (3) community trust and culture, and (4) spill-over effect of COVID-19. Specifically, inadequate political will exerts its effect directly (e.g. limited funding for prepositioning essential cholera supplies) or indirectly (e.g. overlapping policies) on implementing cholera interventions. The healthcare system structure (e.g. centralization of cholera management in a State capital) and limited surveillance tools weaken the capacity to implement cholera interventions. Community trust emerges as integral to strengthening the healthcare system's resilience in mitigating the impacts of cholera outbreaks. Lastly, the spill-over effects of COVID-19 helped promote interventions similar to cholera (e.g. water, sanitation and hygiene) and directly enhanced political will. In conclusion, the study offers insights into the complex barriers and enablers to implementing cholera interventions in Nigeria's cholera-endemic settings. Strong political commitment, strengthening the healthcare system, building community trust and an effective public health system can enhance the implementation of cholera interventions in Nigeria.

Assessment of Childhood Stunting Prevalence over Time and Risk Factors of Stunting in the Healthy Village Programme Areas in Bangladesh.

Childhood stunting is a significant public health concern in Bangladesh. This study analysed the data from the Healthy Village programme, which aims to address childhood stunting in southern coastal Bangladesh. The aim was to assess childhood stunting prevalence over time and explore the risk factors in the programme areas. A cross-sectional, secondary data analysis was conducted for point-prevalence estimates of stunting from 2018 to 2021, including 132,038 anthropometric measurements of under-five children. Multivariate logistic regression analyses were conducted for risk factor analysis (n = 20,174). Stunting prevalence decreased from 51% in 2018 to 25% in 2021. The risk of stunting increased in hardcore poor (aOR: 1.46, 95% CI: 1.27, 1.68) and poor (aOR: 1.50, 95% CI: 1.33, 1.70) versus rich households, children with mothers who were illiterate (aOR: 1.25, 95% CI: 1.09, 1.44) and could read and write (aOR: 1.35, 95% CI: 1.16, 1.56) versus mothers with higher education, and children aged 1-2 years compared with children under one year (aOR: 1.32, 95% CI: 1.20, 1.45). The stunting rate was halved over three years in programme areas, which is faster than the national trend. We recommend addressing socioeconomic inequalities when tackling stunting and providing targeted interventions to mothers during the early weaning period.

An Automated Versatile Diagnostic Workflow for Infectious Disease Detection in Low-Resource Settings.

Laboratory automation effectively increases the throughput in sample analysis, reduces human errors in sample processing, as well as simplifies and accelerates the overall logistics. Automating diagnostic testing workflows in peripheral laboratories and also in near-patient settings -like hospitals, clinics and epidemic control checkpoints- is advantageous for the simultaneous processing of multiple samples to provide rapid results to patients, minimize the possibility of contamination or error during sample handling or transport, and increase efficiency. However, most automation platforms are expensive and are not easily adaptable to new protocols. Here, we address the need for a versatile, easy-to-use, rapid and reliable diagnostic testing workflow by combining open-source modular automation (Opentrons) and automation-compatible molecular biology protocols, easily adaptable to a workflow for infectious diseases diagnosis by detection on paper-based diagnostics. We demonstrated the feasibility of automation of the method with a low-cost Neisseria meningitidis diagnostic test that utilizes magnetic beads for pathogen DNA isolation, isothermal amplification, and detection on a paper-based microarray. In summary, we integrated open-source modular automation with adaptable molecular biology protocols, which was also faster and cheaper to perform in an automated than in a manual way. This enables a versatile diagnostic workflow for infectious diseases and we demonstrated this through a low-cost N. meningitidis test on paper-based microarrays.

Occurrence of major infectious diseases and healthcare seeking among young children with disabilities in Sierra Leone using cross-sectional population-based survey data.

BACKGROUND: Children with disabilities are at risk of worse health outcomes compared to children without functional difficulties. Sierra Leone has one of the world's highest prevalences of functional difficulties among children, but little is known about the co-occurrence of major infectious diseases and healthcare-seeking behaviours among children with disabilities. METHODS: We used household survey cross-sectional data on children 2-4 years old and logistic regression models estimating ORs between functional difficulties and symptoms of infectious diseases including diarrhoea, fever and acute respiratory infection (ARI), adjusted for sex, age and stunting. We also examined whether caregivers sought advice or treatment for the illness from any source and if the child was given any treatment for the illness. RESULTS: There was an increased risk of fever among children with functional difficulty (adjusted OR (AOR)=1.3, 95% CI 1.1 to 1.8) and children with severe functional difficulty (AOR=1.6, 95% CI 1.0 to 2.7). Children with severe functional difficulty were also at increased risk of diarrhoea (AOR=1.8, 95% CI=1.1 to 3.3). There were no significant differences in seeking advice or treatment for diarrhoea, fever or ARI symptoms between the groups. CONCLUSIONS: In Sierra Leone, children with functional difficulties, especially severe functional difficulties, more often have symptoms of major childhood diseases that are known to increase under-5 mortality.

School holidays and respiratory syncytial virus transmission in Sweden: An interrupted time series analysis.

AIM: Respiratory syncytial virus (RSV) represents a significant cause of morbidity for children worldwide, especially for newborns. As RSV vaccines are not routinely used for children yet, non-pharmaceutical interventions (NPIs) represent the main strategy for prevention. The objective of this study was to investigate the correlation between school holidays and RSV transmission. METHODS: Data were collected from the weekly reports on RSV incidence for the 2021/2022 and 2022/2023 seasons in Sweden. The 7-day cumulative incidence of RSV was compared before and after the designated school holidays (Fall, Christmas, and Winter holidays). RESULTS: Our findings reveal an immediate (-1.7%, p < 0.001, 95% CI [-3.1%, -0.4%]) and gradual (-1.4%/week, p < 0.001, 95%CI [-1.8, -1.0]) reduction in RSV incidence following the Fall holiday in 2021, especially among children under 1 year of age, both immediately (-107.6%, p < 0.05, 95% CI [-203.7, -11.5]) and gradually afterwards (-58.5%/week, p < 0.001, 95% CI [-72.7, -44.3]). Mixed results were obtained for the Fall in 2022/2023 and for the Winter and holidays in both the studied years. CONCLUSIONS: While the Fall holiday in 2021/2022 was associated with a decrease in RSV incidence in Sweden, our results do not support a universal effect of school holidays on reducing RSV transmission.

Facility capacity and provider knowledge for cholera surveillance and diarrhoea case management in cholera hotspots in the Democratic Republic of Congo - a mixed-methods study.

BACKGROUND: Wider healthcare-strengthening interventions are recommended in cholera hotspots and could benefit other types of diarrhoeal diseases which contribute to greater mortality than cholera. OBJECTIVE: Describe facility capacity and provider knowledge for case management of diarrhoea and cholera surveillance in cholera hotspots in the Democratic Republic of Congo (DRC) among health facilities, drug shops, and traditional health practitioners. METHODS: We conducted a sequential exploratory mixed-method study, using focus group discussions, facility audits, and provider knowledge questionnaires during September and October 2022 in North Kivu and Tanganyika provinces, Eastern DRC. Content analysis was used for qualitative data. Quantitative data were summarised by facility level and healthcare provider type. Audit and knowledge scores (range 0-100) were generated. Multivariable linear regression estimated association between scores and explanatory factors. Qualitative and quantitative data were triangulated during interpretation. RESULTS: Overall, 244 facilities and 308 providers were included. The mean audit score for health facilities was 51/100 (SD: 17). Private facilities had an -11.6 (95% CI, -16.7 to -6.6) lower adjusted mean score compared to public. Mean knowledge score was 59/100 (95% CI, 57 to 60) for health facility personnel, 46/100 (95% CI, 43 to 48) for drug shop vendors and 37/100 (95% CI, 34 to 39) for traditional health practitioners. Providers had particularly low knowledge concerning when to check for low blood sugar, use of nasogastric tubes, and dosing schedules. Knowledge about case definitions for cholera was similar between groups (range 41-58%) except for traditional health practitioners for the definition during an outbreak 15/73 (21%). CONCLUSIONS: Increasing awareness of cholera case definitions in this context could help improve cholera surveillance and control. Increased support and supervision, especially for private providers, could help ensure facilities are equipped to provide safe care. More nuanced aspects of case management should be emphasised in provider training.

A comparative analysis of non-pharmaceutical interventions for preventing the respiratory syncytial virus in 30 European countries.

AIM: Respiratory syncytial virus (RSV) is a leading cause of childhood respiratory infections. Non-pharmaceutical interventions (NPIs) can help to reduce RSV transmission and our aim was to provide an overview of recommended NPIs across Europe during the 2022-2023 epidemic season. METHODS: The webpages of national European public health agencies and ministries were reviewed and the information they provided on RSV prevention was compared with the December 2022 guidelines from the European Centre for Disease Prevention and Control. RESULTS: We examined 30 countries, leading to 21 issued recommendations for RSV prevention through institutional channels, including six that were specific for the 2022-2023 season. The top five recommendations were: hand and respiratory hygiene (95%), avoiding crowded spaces (67%), staying at home when ill (62%), cleaning household items (57%) and limiting contact with sick people (57%). They also included: face masks (33%), ventilating indoor spaces (29%), properly disposing of contaminated material (13%) and keeping siblings home from preschool if there was a newborn infant in the family (10%). CONCLUSION: There was significant heterogeneity in the NPIs recommended by different countries during RSV epidemics. Ongoing evaluation is essential to optimise the effectiveness of NPIs and adapt to changing RSV patterns.

Exploring different health care providers´ perceptions on the management of diarrhoea in cholera hotspots in the Democratic Republic of Congo: A qualitative content analysis.

Global cholera guidelines support wider healthcare system strengthening interventions, alongside vertical outbreak responses, to end cholera. Well-trained healthcare providers are essential for a resilient health system and can create synergies with childhood diarrhoea, which has higher mortality. We explored how the main provider groups for diarrhoea in cholera hotspots interact, decide on treatment, and reflect on possible limiting factors and opportunities to improve prevention and treatment. We conducted focus group discussions in September 2022 with different healthcare provider types in two urban and two rural cholera hotspots in the North Kivu and Tanganyika provinces in the Eastern Democratic Republic of Congo. Content analysis was used with the same coding applied to all providers. In total 15 focus group discussions with medical doctors (n = 3), nurses (n = 4), drug shop vendors (n = 4), and traditional health practitioners (n = 4) were performed. Four categories were derived from the analysis. (i) Provider dynamics: scepticism between all cadres was prominent, whilst also acknowledging the important role all provider groups have in current case management. (ii) Choice of treatment: affordability and strong caregiver demands shaped by cultural beliefs strongly affected choice. (iii) Financial consideration on access: empathy was strong, with providers finding innovative ways to create access to treatment. Concurrently, financial incentives were important, and providers asked for this to be considered when subsiding treatment. (iv) How to improve: the current cholera outbreak response approach was appreciated however there was a strong wish for broader long-term interventions targeting root causes, particularly community access to potable water. Drug shops and traditional health practitioners should be considered for inclusion in health policies for cholera and other diarrhoeal diseases. Financial incentives for the provider to improve access to low-cost treatment and investment in access to potable water should furthermore be considered.

Linkages between the Sustainable Development Goals and health in Somalia.

BACKGROUND: The Sustainable Development Goals (SDGs) adopted in 2015 compromises 17 universal and indivisible goals for sustainable development, however the interactions between the SDGs in Somalia is not known which is vital for understanding potential synergies and trad-offs between the SDGs. Hence, this study aims to identify and classify the linkages between the SDGs with a focus on health and well-being (SDG 3) in Somalia. METHODS: Following the SDG Synergies approach, 35 leading experts from the public and private sectors as well as academia and civil society gathered for a 2-day workshop in Mogadishu and scored the interactions between the individual SDGs on a seven point-scale from - 3 to + 3. From this, a cross-impact matrix was created, and network models were used to showcase the direct and indirect interactions between the SDGs with a focus on SDG 3 (good health and well-being). RESULTS: Many promoting and a few restricting interactions between the different SDGs were found. Overall, SDG 16 (peace, justice, and strong institutions) influenced the other SDGs the most. When second-order interactions were considered, progress on SDG 16 (peace, justice, and strong institutions) showed the largest positive impact on SDG 3 (good health and well-being). SDG 3 (good health and well-being) was heavily influenced by progress on other SDGs in Somalia and making progress on SDG 3 (good health and well-being) positively influenced progress on all other SDGs. CONCLUSION: The findings revealed that in Somalia, the interactions between the SDGs are mostly synergistic and that SDG 16 (peace, justice, and strong institutions) has a strong influence on progress on other SDGs as well as progress on SDG 3 (good health and well-being). This study highlights the need for a multisectoral strategy to accelerate progress on the SDGs in Somalia in general, and particularly SDG 3 (good health and well-being).

Paediatric, maternal, and congenital mpox: a systematic review and meta-analysis.

BACKGROUND: Although mpox has been detected in paediatric populations in central and west Africa for decades, evidence synthesis on paediatric, maternal, and congenital mpox, and the use of vaccines and therapeutics in these groups, is lacking. A systematic review is therefore indicated to set the research agenda. METHODS: We conducted a systematic review and meta-analysis, searching articles in Embase, Global Health, MEDLINE, CINAHL, Web of Science, Scopus, SciELO, and WHO databases from inception to April 17, 2023. We included studies reporting primary data on at least one case of confirmed, suspected, or probable paediatric, maternal, or congenital mpox in humans or the use of third-generation smallpox or mpox vaccines, targeted antivirals, or immune therapies in at least one case in our population of interest. We included clinical trials and observational studies in humans and excluded reviews, commentaries, and grey literature. A pooled estimate of the paediatric case fatality ratio was obtained using random-effects meta-analysis. This study is registered with PROSPERO (CRD420223336648). FINDINGS: Of the 61 studies, 53 reported paediatric outcomes (n=2123 cases), seven reported maternal or congenital outcomes (n=32 cases), two reported vaccine safety (n=28 recipients), and three reported transmission during breastfeeding (n=4 cases). While a subset of seven observational studies (21 children and 12 pregnant individuals) reported uneventful treatment with tecovirimat, there were no randomised trials reporting safety or efficacy for any therapeutic agent. Among children, the commonest clinical features included rash (86 [100%] of 86), fever (63 [73%] of 86), and lymphadenopathy (40 [47%] of 86). Among pregnant individuals, rash was reported in 23 (100%) of 23; fever and lymphadenopathy were less common (six [26%] and three [13%] of 23, respectively). Most paediatric complications (12 [60%] of 20) arose from secondary bacterial infections. The pooled paediatric case fatality ratio was 11% (95% CI 4-20), I2=75%. Data from 12 pregnancies showed half resulted in fetal death. Research on vaccine and immune globulin safety remains scarce for children and absent for pregnant individuals. INTERPRETATION: Our review highlights critical knowledge gaps in the epidemiology, prevention, and treatment of mpox in children and pregnant individuals, especially those residing in endemic countries. Increased funding, international collaboration, and equitable research is needed to inform mpox control strategies tailored for at-risk communities in endemic countries. FUNDING: None. TRANSLATIONS: For the French, Spanish and Portuguese translations of the abstract see Supplementary Materials section.

How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda.

BACKGROUND: Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response. METHODS: This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery. RESULTS: Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork. CONCLUSIONS: In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

Therapeutic hypothermia after perinatal asphyxia in Vietnam: medium-term outcomes at 18 months - a prospective cohort study.

AIM: To determine neurodevelopmental outcome at 18 months after therapeutic hypothermia for hypoxic-ischaemic encephalopathy (HIE) infants in Vietnam, a low-middle-income country. METHOD: Prospective cohort study investigating outcomes at 18 months in severely asphyxiated outborn infants who underwent therapeutic hypothermia for HIE in Hanoi, Vietnam, during the time period 2016-2019. Survivors were examined at discharge and at 6 and 18 months by a neonatologist, a neurologist and a rehabilitation physician, who were blinded to the infants' clinical severity during hospitalisation using two assessment tools: the Ages and Stages Questionnaire (ASQ) and the Hammersmith Infant Neurological Examination (HINE), to detect impairments and promote early interventions for those who require it. RESULTS: In total, 130 neonates, 85 (65%) with moderate and 45 (35%) with severe HIE, underwent therapeutic hypothermia treatment using phase change material. Forty-three infants (33%) died during hospitalisation and in infancy. Among the 87 survivors, 69 (79%) completed follow-up until 18 months. Nineteen children developed cerebral palsy (8 diplegia, 3 hemiplegia, 8 dyskinetic), and 11 had delayed neurodevelopment. At each time point, infants with a normal or delayed neurodevelopment had significantly higher ASQ and HINE scores (p<0.05) than those with cerebral palsy. CONCLUSION: The rates of mortality and adverse neurodevelopment rate were high and comparable to recently published data from other low-middle-income settings. The ASQ and HINE were useful tools for screening and evaluation of neurodevelopment and neurological function.

Physician's conceptions of the decision-making process when managing febrile infants ≤ 60 days old: a phenomenographic qualitative study.

BACKGROUND: The management of febrile infants aged ≤ 60 days and adherence to guidelines vary greatly. Our objective was to describe the process of decision-making when managing febrile infants aged ≤ 60 days and to describe the factors that influenced this decision. METHODS: We conducted 6 focus group discussions with 19 clinically active physicians in the pediatric emergency departments of 2 university hospitals in Skåne region, Sweden. We followed an inductive qualitative design, using a phenomenological approach. A second-order perspective was used, focusing on how physicians perceived the phenomenon (managing fever in infants) rather than the phenomenon itself. The transcribed interviews were analyzed using a 7-step approach. RESULTS: Performing a lumbar puncture (LP) was conceived as a complex, emotionally and mentally laden procedure and dominated the group discussions. Three central categories emerged as factors that influenced the decision-making process on whether to perform an LP: 1) a possible focus of infection that could explain the origin of the fever, 2) questioning whether the temperature at home reported by the parents was a fever, especially if it was ≤ 38.2°C, and 3) the infant's general condition and questioning the need for LP in case of well-appearing infants. Around these 3 central categories evolved 6 secondary categories that influenced the decision-making process of whether to perform an LP or not: 1) the physicians' desire to be able to trust their judgement, 2) fearing the risk of failure, 3) avoiding burdensome work, 4) taking others into account, 5) balancing guidelines and resources, and 6) seeing a need to practice and learn to perform LP. CONCLUSIONS: The difficulty and emotional load of performing an LP were important factors that influenced the decision-making process regarding whether to perform an LP. Physicians highlighted the importance of being able to rely on their clinical judgment and make independent decisions. Guidelines may consider allowing a degree of flexibility and independent thinking to take into account patients' characteristics and needs.

The pneumococcal conjugate vaccine had a sustained effect on Swedish children 8 years after its introduction.

AIM: The pneumococcal conjugate vaccine, which covered seven serotypes of Streptococcus pneumoniae (PCV7), was introduced in Stockholm, Sweden, in 2007. It was replaced by a 13-valent vaccine (PCV13) in 2011. We previously reported a decreased incidence of pneumonia and sinusitis among young children 4 years after the introduction of the PCV7. This study followed the incidence of pneumonia, sinusitis, mastoiditis and meningitis for four more years. METHODS: We studied validated hospital registry data covering children up to 17 years of age, who were hospitalised in the Stockholm region from 2003 to 2016, when the child population peaked at 485 687. All 11 115 cases diagnosed with pneumonia, coded as bacterial pneumonia, sinusitis, mastoiditis, bacterial meningitis or empyema, were identified. The controls had viral pneumonia or pyelonephritis. RESULTS: The incidence rates for children under 2 years of age hospitalised for sinusitis, mastoiditis and meningitis decreased significantly by 61%-79% during the eight-year post-vaccination period. Hospitalisations for bacterial pneumonia decreased by 19%-25% in the same age group. These changes were probably due to both the vaccines and changes in diagnosis routines. CONCLUSION: The effect of vaccination on children under 2 years of age was sustained 8 years after the introduction of the pneumococcal conjugate vaccines.

Outcomes of SARS-CoV-2 Omicron Variant Infections Compared With Seasonal Influenza and Respiratory Syncytial Virus Infections in Adults Attending the Emergency Department: A Multicenter Cohort Study.

BACKGROUND: There is a controversy over the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in an era of less virulent variants and an increasing population immunity. We compared outcomes in adults attending the emergency department (ED) with an Omicron, influenza, or respiratory syncytial virus (RSV) infection. METHODS: Retrospective multicenter cohort study including adults attending the ED in 6 acute care hospitals in Stockholm County, Sweden, with an Omicron, influenza, or RSV infection during 2021-2022 and 2015-2019. During 2021-2022, patients were tested for all 3 viruses by multiplex polymerase chain reaction (PCR) testing. The primary outcome was 30-day all-cause mortality. Secondary outcomes were 90-day all-cause mortality, hospitalization, and intensive care unit (ICU) admission. RESULTS: A total of 6385 patients from 2021-2022 were included in the main analyses: 4833 Omicron, 1099 influenza, and 453 RSV. The 30-day mortality was 7.9% (n = 381) in the Omicron, 2.5% (n = 28) in the influenza, and 6.0% (n = 27) in the RSV cohort. Patients with Omicron had an adjusted 30-day mortality odds ratio (OR) of 2.36 (95% confidence interval [CI] 1.60-3.62) compared with influenza and 1.42 (95% CI .94-2.21) compared with RSV. Among unvaccinated Omicron patients, stronger associations were observed compared with both influenza (OR 5.51 [95% CI 3.41-9.18]) and RSV (OR 3.29 [95% CI 2.01-5.56]). Similar trends were observed for secondary outcomes. Findings were consistent in comparisons with 5709 pre-pandemic influenza 995 RSV patients. CONCLUSIONS: In patients attending the ED, infections with Omicron were both more common and associated with more severe outcomes compared with influenza and RSV, in particular among unvaccinated patients.