Household Costs Associated with Hospitalization of Children with Severe Pneumonia in Quito, Ecuador.

Pneumonia remains a leading cause of morbidity and mortality in young children. The total cost of pneumonia-related hospitalization, including household-level cost, is poorly understood. To better understand this burden in an urban setting in South America, we incorporated a cost study into a trial assessing zinc supplements in treatment of severe pneumonia among children aged 2-59 months at a public hospital in Quito, Ecuador, which provides such treatment at no charge. Data were collected from children's caregivers at hospitalization and discharge on out-of-pocket payments for medical and nonmedical items, and on employment and lost work time. Analyses encompassed three categories: direct medical costs, direct nonmedical costs, and indirect costs, which covered foregone wages (from caregivers' self-reported lost earnings) and opportunity cost of caregivers' lost time (based on the unskilled labor wage in Ecuador). Caregivers of 153 children completed all questionnaires. Overall, 57% of children were aged less than 12 months, and 46% were female. Just over 50% of mothers and fathers had completed middle school. Most reported direct costs, which averaged $33. Most also reported indirect costs, the mean of which was $74. Fifty-seven reported lost earnings (mean = $79); 29 reported lost time (estimated mean cost = $37). Stratified analyses revealed similar costs for children < 12 months and ≥ 12 months, with variations for specific items. Costs for hospital-based treatment of severe pneumonia in young children represent a major burden for households in low- to middle-income settings, even when such treatment is intended to be provided at no cost.

Etiology of severe pneumonia in Ecuadorian children.

BACKGROUND: In Latin America, community-acquired pneumonia remains a major cause of morbidity and mortality among children. Few studies have examined the etiology of pneumonia in Ecuador. METHODS: This observational study was part of a randomized, double blind, placebo-controlled clinical trial conducted among children aged 2-59 months with severe pneumonia in Quito, Ecuador. Nasopharyngeal and blood samples were tested for bacterial and viral etiology by polymerase chain reaction. Risk factors for specific respiratory pathogens were also evaluated. RESULTS: Among 406 children tested, 159 (39.2%) had respiratory syncytial virus (RSV), 71 (17.5%) had human metapneumovirus (hMPV), and 62 (15.3%) had adenovirus. Streptococcus pneumoniae was identified in 37 (9.2%) samples and Mycoplasma pneumoniae in three (0.74%) samples. The yearly circulation pattern of RSV (P = 0.0003) overlapped with S. pneumoniae, (P = 0.03) with most cases occurring in the rainy season. In multivariable analysis, risk factors for RSV included younger age (adjusted odds ratio [aOR] = 1.9, P = 0.01) and being underweight (aOR = 1.8, P = 0.04). Maternal education (aOR = 0.82, P = 0.003), pulse oximetry (aOR = 0.93, P = 0.005), and rales (aOR = 0.25, P = 0.007) were associated with influenza A. Younger age (aOR = 3.5, P = 0.007) and elevated baseline respiratory rate were associated with HPIV-3 infection (aOR = 0.94, P = 0.03). CONCLUSION: These results indicate the importance of RSV and influenza, and potentially modifiable risk factors including undernutrition and future use of a RSV vaccine, when an effective vaccine becomes available. TRIAL REGISTRATION: ClinicalTrials.gov NCT 00513929.

Zinc as an adjunct to the treatment of severe pneumonia in Ecuadorian children: a randomized controlled trial.

BACKGROUND: Studies of zinc as an adjunct to treatment of severe pneumonia in children have shown mixed results, possibly because of poor information on zinc status and respiratory pathogens. OBJECTIVE: We evaluated the effect of zinc given with standard antimicrobial treatment on the duration of respiratory signs in children with severe pneumonia. Zinc status and pathogens were assessed. DESIGN: Children aged 2-59 mo with severe pneumonia who were admitted to the main children's hospital in Quito, Ecuador, were given standard antibiotics and randomly allocated to receive zinc supplements twice daily or a placebo. Measurements included anthropometric variables, breastfeeding, hemoglobin, plasma zinc, and common bacteria/viral respiratory pathogens. The primary outcome was time to resolution of respiratory signs. The secondary outcome was treatment failure. RESULTS: We enrolled 225 children in each group. There was no difference between groups in time to resolution of respiratory signs or treatment failure; pathogens were not associated with outcomes. Tachypnea and hypoxemia resolved faster in older children (P = 0.0001) than in younger ones. Higher basal zinc concentration (P = 0.011) and better height-for-age z score (HAZ) (P = 0.044) were associated with faster resolution of chest indrawing. Better weight-for-height z score (WHZ) (P = 0.031) and HAZ (P = 0.048) were associated with faster resolution of tachypnea. Increased C-reactive protein was associated with a longer duration of tachypnea (P = 0.044). CONCLUSIONS: Zinc did not affect time to pneumonia resolution or treatment failure, nor did type of respiratory pathogens affect outcomes. Higher basal zinc and better HAZ and WHZ were associated with reduced time to resolution of respiratory signs. These results suggest the need for prevention of chronic zinc deficiency and improvement of general nutritional status among Ecuadorian children.

Setting priorities for zinc-related health research to reduce children's disease burden worldwide: an application of the Child Health and Nutrition Research Initiative's research priority-setting method.

OBJECTIVE: To make the best use of limited resources for supporting health-related research to reduce child mortality, it is necessary to apply a suitable method to rank competing research options. The Child Health and Nutrition Research Initiative (CHNRI) developed a new methodology for setting health research priorities. To broaden experience with this priority-setting technique, we applied the method to rank possible research priorities concerning the control of Zn deficiency. Although Zn deficiency is not generally recognized as a direct cause of child mortality, recent research indicates that it predisposes children to an increased incidence and severity of several of the major direct causes of morbidity and mortality. DESIGN: Leading experts in the field of Zn research in child health were identified and invited to participate in a technical working group (TWG) to establish research priorities. The individuals were chosen to represent a wide range of expertise in Zn nutrition. The seven TWG members submitted a total of ninety research options, which were then consolidated into a final list of thirty-one research options categorized by the type of resulting intervention. RESULTS: The identified priorities were dominated by research investment options targeting Zn supplementation, and were followed by research on Zn fortification, general aspects of Zn nutrition, dietary modification and other new interventions. CONCLUSIONS: In general, research options that aim to improve the efficiency of an already existing intervention strategy received higher priority scores. Challenges identified during the implementation of the methodology and suggestions to modify the priority-setting procedures are discussed.

Dose-response trial of prophylactic zinc supplements, with or without copper, in young Ecuadorian children at risk of zinc deficiency.

BACKGROUND: Multiple studies have shown the benefits of zinc supplementation among young children in high-risk populations. However, the optimal dose and safe upper level of zinc have not been determined. OBJECTIVES: The objectives of this study were to measure the effects of different doses of supplemental zinc on the plasma zinc concentration, morbidity, and growth of young children; to detect any adverse effects of 10 mg supplemental Zn on markers of copper or iron status; and to determine whether any adverse effects are alleviated by providing copper with zinc. DESIGN: This randomized, double-masked, community-based intervention trial was conducted in 631 Ecuadorian children who were 12-30 mo old at baseline and who had initial length-for-age z scores <-1.3. Children received 1 of 5 daily supplements for 6 mo: 3, 7, or 10 mg Zn as zinc sulfate, 10 mg Zn + 0.5 mg Cu as copper sulfate, or placebo. RESULTS: The change in plasma zinc concentration from baseline was positively related to the zinc dose (P < 0.001). Zinc supplementation, including doses as low as 3 mg/d, reduced the incidence of diarrhea by 21-42% (P < 0.01). There were no other significant group-wise differences. CONCLUSIONS: Zinc supplementation with a dose as low as 3 mg/d increased plasma zinc concentrations and reduced diarrhea incidence in the study population. There were no observed adverse effects of 10 mg Zn/d on indicators of copper or iron status. The current tolerable upper level of zinc recommended by the Institute of Medicine should be reassessed for young children.

Growth and micronutrient status in children receiving a fortified complementary food.

Linear growth retardation and anemia are the most prevalent nutritional problems in the world; effective interventions are urgently needed. We evaluated Ecuador's National Food Nutrition Program (PANN 2000) that included a micronutrient-fortified complementary food (FCF), Mi Papilla, in poor periurban and rural communities of Ecuador. The program is preventive and targeted to all infants and young children living in poor communities and receiving government health services. We compared dietary intake, micronutrient status, and growth over 11 mo in a cohort of children from the catchment areas of the PANN 2000 with same-age control children in nearby communities eligible to enter the program 1 y later. PANN 2000 children enrolled in the program when they were age 9-14 mo and were age 20-25 mo at the final survey. They consumed significantly more energy, protein, fat, iron, zinc, vitamin A, and calcium than control children because of their FCF consumption. Anemia, 76% in both groups at baseline, fell to 27% in PANN 2000 children but only to 44% in control children (P < 0.001). The odds of being anemic were 58% lower for PANN 2000 children (P = 0.003). The effects on linear growth and weight were limited to children who were older when the program began (12-14 mo) and were significant for weight (interaction with age, 0.38 kg; P = 0.029) and positive but not significant for length (0.66 cm; P = 0.08). An FCF, including ferrous sulfate, delivered through public health services, is highly effective in improving weight and hemoglobin and reducing anemia.

Effects of moderate doses of vitamin A as an adjunct to the treatment of pneumonia in underweight and normal-weight children: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Randomized controlled trials have shown inconsistent responses of childhood pneumonia to the use of vitamin A as an adjunct to the standard treatment of pneumonia. OBJECTIVE: We evaluated the effect of a moderate dose of vitamin A as an adjunct to standard antimicrobial treatment on the duration of respiratory signs in children with pneumonia. DESIGN: Children, aged 2-59 mo, with pneumonia and weight-for-age <50th percentile who had been admitted to the Baca Ortíz Children's Hospital in Quito, Ecuador, were randomly assigned to receive 50,000 IU (aged 2-12 mo) or 100,000 IU (aged >12-59 mo) vitamin A or a placebo. RESULTS: Of the 287 children enrolled, 145 received vitamin A and 142 received placebo. No overall differences were observed between the 2 groups in the duration of signs of pneumonia. Multiple linear regression showed a significant interaction between basal serum retinol concentration and vitamin A group for the time (in h) to remission of respiratory signs (beta = -3.57, SE = 1.09, P = 0.001). Duration of clinical signs was less in children with basal serum retinol concentrations >200 microg/L who received vitamin A supplements than in children with similar concentrations who received placebo (69.9 +/- 49.9 h compared with 131.3 +/- 143.9 h; P = 0.049). CONCLUSIONS: Overall, we found no effect of a moderate dose of vitamin A supplementation on the duration of uncomplicated pneumonia in underweight or normal-weight children aged <5 y. However, a beneficial effect was seen in children with high basal serum retinol concentrations.

Selenium serum concentrations in malnourished Ecuadorian children: a case-control study.

Little is known about the selenium status of children living in the Andean regions of South America, which commonly have volcanic soil with low selenium content. Human selenium deficiency has been hypothesized to have a negative impact on immune function and to increase the risk of infection. The objective of this study was to evaluate the serum selenium concentrations of severely malnourished children living in urban and rural Andean Ecuador, and to compare them to a control group of normally nourished children from the same communities. Forty-three children, aged six to 36 months, with marasmus or kwashiorkor and 30 control children were enrolled from July to November 1993 in Quito, Ecuador. Serum selenium concentrations were lower in the children with marasmus (0.91 +/- 0.28 microM/L, n = 21) and kwashiorkor (0.37 +/- 0.15 microM/L, n = 22) than in those who were normally nourished (1.77 +/- 0.75 microM/L, n = 30, p < 0.001 for each difference). The serum selenium concentrations in children with kwashiorkor were significantly lower than those in children with marasmus (p < 0.001). All 22 of the children with kwashiorkor, 15 of the 21 children with marasmus, and five of the 30 normal children had serum levels < 1.08 microM/L (8.5 micrograms/dL) (chi 2 = 38.4, p < 0.00000001). In the Andean regions of Ecuador, selenium deficiency is prevalent in children with protein and caloric deficiency. Furthermore, 17% of Ecuadorian children with normal weight-for age-Z score are selenium-deficient.