Characterising sources of PM2·5 exposure for school children with asthma: a personal exposure study across six cities in sub-Saharan Africa.

BACKGROUND: Air pollution is the second largest risk to health in Africa, and children with asthma are particularly susceptible to its effects. Yet, there is a scarcity of air pollution exposure data from cities in sub-Saharan Africa. We aimed to identify potential exposure reduction strategies for school children with asthma living in urban areas in sub-Saharan Africa. METHODS: This personal exposure study was part of the Achieving Control of Asthma in Children in Africa (ACACIA) project. Personal exposure to particulate matter (PM) was monitored in school children in six cities in sub-Saharan Africa (Blantyre, Malawi; Durban, South Africa; Harare, Zimbabwe; Kumasi, Ghana; Lagos, Nigeria; and Moshi, Tanzania). Participants were selected if they were aged 12-16 years and had symptoms of asthma. Monitoring was conducted between June 21, and Nov 26, 2021, from Monday morning (approximately 1000 h) to Friday morning (approximately 1000 h), by use of a bespoke backpack with a small air pollution monitoring unit with an inbuilt Global Positioning System (GPS) data logger. Children filled in a questionnaire detailing potential sources of air pollution during monitoring and exposures were tagged into three different microenvironments (school, commute, and home) with GPS coordinates. Mixed-effects models were used to identify the most important determinants of children's PM2·5 (PM <2·5 µm in diameter) exposure. FINDINGS: 330 children were recruited across 43 schools; of these, 297 had valid monitoring data, and 1109 days of valid data were analysed. Only 227 (20%) of 1109 days monitored were lower than the current WHO 24 h PM2·5 exposure health guideline of 15 µg/m3. Children in Blantyre had the highest PM2·5 exposure (median 41·8 µg/m3), whereas children in Durban (16·0 µg/m3) and Kumasi (17·9 µg/m3) recorded the lowest exposures. Children had significantly higher PM2·5 exposures at school than at home in Kumasi (median 19·6 µg/m3vs 14·2 µg/m3), Lagos (32·0 µg/m3vs 18·0 µg/m3), and Moshi (33·1 µg/m3vs 23·6 µg/m3), while children in the other three cities monitored had significantly higher PM2·5 exposures at home and while commuting than at school (median 48·0 µg/m3 and 43·2 µg/m3vs 32·3 µg/m3 in Blantyre, 20·9 µg/m3 and 16·3 µg/m3vs 11·9 µg/m3 in Durban, and 22·7 µg/m3 and 25·4 µg/m3vs 16·4 µg/m3 in Harare). The mixed-effects model highlighted the following determinants for higher PM2·5 exposure: presence of smokers at home (23·0% higher exposure, 95% CI 10·8-36·4), use of coal or wood for cooking (27·1%, 3·9-56·3), and kerosene lamps for lighting (30·2%, 9·1-55·2). By contrast, 37·2% (95% CI 22·9-48·2) lower PM2·5 exposures were found for children who went to schools with paved grounds compared with those whose school grounds were covered with loose dirt. INTERPRETATION: Our study suggests that the most effective changes to reduce PM2·5 exposures in these cities would be to provide paving in school grounds, increase the use of clean fuel for cooking and light in homes, and discourage smoking within homes. The most efficient way to improve air quality in these cities would require tailored interventions to prioritise different exposure-reduction policies in different cities. FUNDING: UK National Institute for Health and Care Research.

A cross-country qualitative analysis of teachers' perceptions of asthma care in sub-Saharan Africa.

Asthma is the most common chronic respiratory disease among school-going adolescents worldwide. However, the burden of severe asthma is highest in Sub-Saharan Africa. This study aimed to explore teachers' perceptions of asthma care across six African countries. We conducted focus group discussions (FGDs) using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and analysed thematically. FGDs were conducted in Kumasi(Ghana), Blantyre (Malawi), Lagos (Nigeria), Durban (South Africa), Kampala (Uganda), and Harare (Zimbabwe) between 01 November 2020 and 30 June 2021. We identified two key themes related to asthma care; barriers to asthma care and suggestions to improve the care of adolescents with asthma. Barriers reported by teachers included a lack of knowledge and skills among themselves, adolescents, and caregivers. In addition, some traditional beliefs of teachers on asthma exacerbated challenges with asthma care in schools. Regarding suggestions, most teachers identified a need for all-inclusive asthma training programmes for teachers, adolescents and caregivers, focusing on acute episodes and mitigating triggers. Utilising teachers with personal experiences with asthma to advocate and support these initiatives was suggested. Further suggestions included the need for annual screening to enable early identification of adolescents with asthma and clarify restrictions on teachers administering asthma medications. Teachers across African schools identify multiple barriers to asthma care. Structured school education programs and annual asthma screening are key to addressing some barriers to care.

In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset.

OBJECTIVES: We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors. METHODS: We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors. RESULTS: Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32). CONCLUSION: Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.

Assembling a global database of child pneumonia studies to inform WHO pneumonia management algorithm: Methodology and applications.

Background: The existing World Health Organization (WHO) pneumonia case management guidelines rely on clinical symptoms and signs for identifying, classifying, and treating pneumonia in children up to 5 years old. We aimed to collate an individual patient-level data set from large, high-quality pre-existing studies on pneumonia in children to identify a set of signs and symptoms with greater validity in the diagnosis, prognosis, and possible treatment of childhood pneumonia for the improvement of current pneumonia case management guidelines. Methods: Using data from a published systematic review and expert knowledge, we identified studies meeting our eligibility criteria and invited investigators to share individual-level patient data. We collected data on demographic information, general medical history, and current illness episode, including history, clinical presentation, chest radiograph findings when available, treatment, and outcome. Data were gathered separately from hospital-based and community-based cases. We performed a narrative synthesis to describe the final data set. Results: Forty-one separate data sets were included in the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) database, 26 of which were hospital-based and 15 were community-based. The PREPARE database includes 285 839 children with pneumonia (244 323 in the hospital and 41 516 in the community), with detailed descriptions of clinical presentation, clinical progression, and outcome. Of 9185 pneumonia-related deaths, 6836 (74%) occurred in children <1 year of age and 1317 (14%) in children aged 1-2 years. Of the 285 839 episodes, 280 998 occurred in children 0-59 months old, of which 129 584 (46%) were 2-11 months of age and 152 730 (54%) were males. Conclusions: This data set could identify an improved specific, sensitive set of criteria for diagnosing clinical pneumonia and help identify sick children in need of referral to a higher level of care or a change of therapy. Field studies could be designed based on insights from PREPARE analyses to validate a potential revised pneumonia algorithm. The PREPARE methodology can also act as a model for disease database assembly.

Derivation and validation of a novel risk assessment tool to identify children aged 2-59 months at risk of hospitalised pneumonia-related mortality in 20 countries.

INTRODUCTION: Existing risk assessment tools to identify children at risk of hospitalised pneumonia-related mortality have shown suboptimal discriminatory value during external validation. Our objective was to derive and validate a novel risk assessment tool to identify children aged 2-59 months at risk of hospitalised pneumonia-related mortality across various settings. METHODS: We used primary, baseline, patient-level data from 11 studies, including children evaluated for pneumonia in 20 low-income and middle-income countries. Patients with complete data were included in a logistic regression model to assess the association of candidate variables with the outcome hospitalised pneumonia-related mortality. Adjusted log coefficients were calculated for each candidate variable and assigned weighted points to derive the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) risk assessment tool. We used bootstrapped selection with 200 repetitions to internally validate the PREPARE risk assessment tool. RESULTS: A total of 27 388 children were included in the analysis (mean age 14.0 months, pneumonia-related case fatality ratio 3.1%). The PREPARE risk assessment tool included patient age, sex, weight-for-age z-score, body temperature, respiratory rate, unconsciousness or decreased level of consciousness, convulsions, cyanosis and hypoxaemia at baseline. The PREPARE risk assessment tool had good discriminatory value when internally validated (area under the curve 0.83, 95% CI 0.81 to 0.84). CONCLUSIONS: The PREPARE risk assessment tool had good discriminatory ability for identifying children at risk of hospitalised pneumonia-related mortality in a large, geographically diverse dataset. After external validation, this tool may be implemented in various settings to identify children at risk of hospitalised pneumonia-related mortality.

The environmental impact of inhaled therapy: making informed treatment choices.

When selecting the best inhaler and drug combination for a patient with respiratory disease, a number of factors should be considered. While efficacy and safety of medical treatments are always a priority, in recent years the environmental impacts of all aspects of life have become an increasingly necessary consideration and inhaled therapies are no exception. The carbon footprint of an item, individual or organisation is one of the most important and quantifiable environmental impacts, assessed by the amount of greenhouse gases (often expressed in terms of carbon dioxide equivalents) generated throughout the life cycle. The two most commonly prescribed and manufactured inhaler types worldwide are pressurised metered-dose inhalers (pMDIs) containing hydrofluorocarbon (HFC) propellants and dry powder inhalers (DPIs). Most of the carbon footprint of current pMDIs is a result of the propellants that they contain (HFC-134a and HFC-227ea, which are potent greenhouse gases). In comparison, the powder in DPIs is dispersed by the patient's own inhalation, meaning DPIs do not contain a propellant and have a lower carbon footprint than most pMDIs currently available. Soft mist inhalers are another propellant-free option: the device contains a spring, which provides the energy to disperse the aqueous medication. In this review, we examine the published data on carbon footprint data for inhalers, providing an analysis of potential implications for treatment decision making and industry initiatives.

Validation of visual estimation of neonatal jaundice in low-income and middle-income countries: a multicentre observational cohort study.

OBJECTIVE: Determine the sensitivity and specificity of neonatal jaundice visual estimation by primary healthcare workers (PHWs) and physicians as predictors of hyperbilirubinaemia. DESIGN: Multicentre observational cohort study. SETTING: Hospitals in Chandigarh and Delhi, India; Dhaka, Bangladesh; Durban, South Africa; Kumasi, Ghana; La Paz, Bolivia. PARTICIPANTS: Neonates aged 1-20 days (n=2642) who presented to hospitals for evaluation of acute illness. Infants referred for any reason from another health facility or those needing immediate cardiopulmonary resuscitation were excluded. OUTCOME MEASURES: Infants were evaluated for distribution (head, trunk, distal extremities) and degree (mild, moderate, severe) of jaundice by PHWs and physicians. Serum bilirubin level was determined for infants with jaundice, and analyses of sensitivity and specificity of visual estimations of jaundice used bilirubin thresholds of >260 µmol/L (need for phototherapy) and >340 µmol/L (need for emergency intervention in at-risk and preterm babies). RESULTS: 1241 (47.0%) neonates had jaundice. High sensitivity for detecting neonates with serum bilirubin >340 µmol/L was found for 'any jaundice of the distal extremities (palms or soles) OR deep jaundice of the trunk or head' for both PHWs (89%-100%) and physicians (81%-100%) across study sites; specificity was more variable. 'Any jaundice of the distal extremities' identified by PHWs and physicians had sensitivity of 71%-100% and specificity of 55%-95%, excluding La Paz. For the bilirubin threshold >260 µmol/L, 'any jaundice of the distal extremities OR deep jaundice of the trunk or head' had the highest sensitivity across sites (PHWs: 58%-93%, physicians: 55%-98%). CONCLUSIONS: In settings where serum bilirubin cannot be measured, neonates with any jaundice on the distal extremities should be referred to a hospital for evaluation and management, where delays in serum bilirubin measurement and appropriate treatment are anticipated following referral, the higher sensitivity sign, any jaundice on the distal extremities or deep jaundice of the trunk or head, may be preferred.

Decreased Mortality After Establishing a Pediatric Emergency Unit at an Urban Referral Hospital in Ghana.

ABSTRACT: Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in low- and middle-income countries. Limited reports have shown that process improvements and prioritization of emergency care for children presenting to the hospital can improve pediatric hospital mortality.A dedicated pediatric emergency unit (PEU) was established for nontrauma emergencies at a busy teaching and referral hospital in Kumasi, Ghana, in response to high inpatient mortality early during hospitalization. The PEU was designed to identify and separate critically ill children from more stable children on admission. Locally available hospital resources were reallocated from other areas of the hospital to prioritize staffing and supplies for the PEU.A multiyear data set of nonnewborn inpatient mortality was analyzed with a change point model to find the point at which mortality changed the most within the Department of Child Health or the maximum likelihood estimate. Relative risk of mortality for the periods 1 and 2 years immediately before and after the implementation of the PEU and each individual year compared with its preceding year was analyzed to further establish a temporal correlation of changes in mortality rates to the PEU implementation. Individual years were also analyzed against preimplementation data to establish the durability of mortality improvements.Patient mortality decreased over the analyzed period with the maximum change point strongly associated with implementation of the PEU. Relative risk values of mortality 1 year and 2 years immediately before and after implementation of the PEU were 0.70 (0.62-0.78) and 0.69 (0.64-0.74) respectively, representing a one-third reduction in mortality. The only other mortality improvements seen in the year-to-year analysis were between July 2004-June 2005 compared with July 2005-June 2006 with a relative risk of 0.86 (0.77-0.96).Prioritizing and redirecting limited resources toward pediatric emergency care in low- and middle-income country hospitals is associated with reductions in inpatient mortality that are both immediate and sustained.

Increased prevalence of hypertension in Ghana: New 2017 American College of Cardiology/American Hypertension Association hypertension guidelines application.

BACKGROUND: We estimated the prevalence and socio-demographic risk factors of hypertension among Ghanaian adults as per the Joint National Committee 7 and the 2017 American College of Cardiology/American Hypertension Association hypertension thresholds used for diagnosis and treatment. METHODS: This cross-sectional analysis included 12 151 adults (8295 females and 3856 males) aged 18 years or older who participated in the 2014 Ghana Demographic and health Survey. Multiple logistic regression models were applied to obtain risk factors associated with hypertension as per both guidelines. RESULTS: Overall, 30.43% (n = 3698) and 11.48% (n = 1395) respondents had hypertension as per the 2017 ACC/AHA and JNC7 guidelines, respectively. The following factors were significant according to the 2017 ACC/AHA guideline: 55-64 years (adjusted odds ratio (aOR) = 6.42, 95% confidence interval (CI): 4.70-8.77), 45-54 years (aOR = 5.72, 95% CI = 4.70-6.85), 3544 years (aOR = 3.91, 95% CI = 3.33-4.59), and 25-34 years (aOR = 2.05, 95% CI = 1.77-2.37) age groups. Males (aOR = 1.39, 95% CI = 1.23-1.53), and urban residents (aOR = 1.18, 95% CI = 1.05-1.38). All the above risk factors were significant according to the JNC7 guideline too. Factors positively associated with only the 2017 ACC/AHA guideline included: middle income (aOR = 1.20, 95% CI = 1.02-1.42) and richest (aOR = 1.36, 95% CI = 1.10-1.69) wealth quintiles, whereas manual (aOR = 1.37, 95% CI = 1.02-1.86) was positively associated with the JNC7 guidelines only. CONCLUSIONS: We conclude that adopting the ACC/AHA guidelines would lead to a substantial increase in the prevalence of hypertension among Ghanaian adults, thus, hypertension prevention and control should be prioritized.

Achieving Control of Asthma in Children in Africa (ACACIA): protocol of an observational study of children's lung health in six sub-Saharan African countries.

INTRODUCTION: Little is known about asthma control in the rising number of African children who suffer from this condition. The Achieving Control of Asthma in Children in Africa (ACACIA) study is an observational study collecting evidence about paediatric asthma in urban areas of Ghana, Malawi, Nigeria, South Africa, Uganda and Zimbabwe. The primary objectives are: (1) to identify 3000 children aged between 12 years and 14 years with asthma symptoms; and (2) to assess their asthma control, current treatment, knowledge of and attitudes to asthma and barriers to achieving good control. Secondary objective is to develop interventions addressing identified barriers to good symptom control. METHODS AND ANALYSIS: Each centre will undertake screening to identify 500 school children with asthma symptoms using questions from the Global Asthma Network's questionnaire. Children identified to have asthma symptoms will fill in a digital survey, including: Asthma Control Test, questions on medication usage and adherence, medical care, the Brief-Illness Perception questionnaire and environmental factors. Exhaled nitric oxide testing and prebronchodilator and postbronchodilator spirometry will be performed. A subgroup of children will participate in focus group discussions. Results will be analysed using descriptive statistics and comparative analysis. Informed by these results, we will assess the feasibility of potential interventions, including the adaption of a UK-based theatre performance about asthma attitudes and digital solutions to improve asthma management. ETHICS AND DISSEMINATION: The ACACIA study has been reviewed by the Queen Mary University of London Ethics of Research Committee in the UK. All African centres have received local ethical approval for this study. Study results will be published in academic journals and at conferences. Study outputs will be communicated to the public via newsfeeds on the ACACIA website and Twitter, and through news media outlets and other local dissemination. TRIAL REGISTRATION NUMBER: 269211.

Prevalence and risk factors for dyslipidemia among adults in rural and urban China: findings from the China National Stroke Screening and prevention project (CNSSPP).

BACKGROUND: Dyslipidemia is a modifiable risk factor for cardiovascular disease (CVD). We investigated the prevalence and associated risk factors of dyslipidemia- raised total cholesterol (TC), raised triglycerides (TG), raised low-density lipoprotein (LDL-C), low high-density lipoprotein (HDL-C), and raised non-high-density lipoprotein (non-HDL-C) in rural and urban China. METHODS: We analyzed data from 136,945 participants aged 40-100 years of the CNSSPP project for 2014. Dyslipidemia was defined by the NCEP-ATP III and the 2016 Chinese guidelines for the management of dyslipidemia in adults. Complete data on demographic, metabolic and lifestyle characteristics were used. Chi-square tests and multivariable logistic regression were used to obtain age- and sex-adjusted prevalence and risk factors for dyslipidemia among participants. RESULTS: A total of 53.1% participants lived in rural areas. The prevalence of dyslipidemia was similar among rural and urban participants (43.2% vs. 43.3%). Regarding the components of dyslipidemia: urban compared with rural participants had a higher prevalence of low HDL-C (20.8% vs. 19.2%), whereas the prevalence of raised LDL-C (7.8% vs. 8.3%), raised TC (10.9% vs.11.8%) and raised non-HDL-C (10.0% vs. 10.9%) were lower in urban residents, (all p < 0.001). Women were more likely to have raised TC than men (adjusted OR [AOR] =1.83, 95% confidence interval [CI]:1.75-1.91), raised LDL-C (AOR = 1.55, 95% CI: 1.47-1.63) and high non-HDL-C (AOR = 1.52 95% CI: 1.45-1.59) (all p < 0.001). Compared with rural, urban participants had higher odds of dyslipidemia: low HDL-C (AOR = 1.04, 95% CI: 1.01-1.07), and raised TG (AOR = 1.06, 95% CI: 1.04-1.09). Hypertension and current drinker were less likely to get low HDL-C with AOR 0.93 (95% CI: 0.90-0.96) and AOR 0.73 (95% CI: 0.70-75), respectively. Overweight, obesity, central obesity and diabetes had higher odds of all dyslipidemias (p < 0.001). CONCLUSIONS: Low HDL-C was higher in urban areas, whereas the remaining dyslipidemia types were more common in rural areas. Dyslipidemia was more common in women in both areas of residence. Overweight, obesity, central obesity and diabetes were associated with dyslipidemias. The need to intensify intervention programs to manage dyslipidemia and risk factors should be prioritized.

Sustained impact of rotavirus vaccine introduction on rotavirus gastroenteritis hospitalizations in children <5 years of age, Ghana, 2009-2016.

INTRODUCTION: Ghana introduced monovalent rotavirus vaccine in April 2012. We sought to determine the long-term impact of routine rotavirus vaccination on rotavirus gastroenteritis hospitalizations in Ghana during the first 4 years following rotavirus vaccine introduction. METHODS: Active sentinel surveillance for acute gastroenteritis hospitalizations among children <5 years of age was conducted at two sites from July 2009 through June 2016. Stool specimens were collected from enrolled children and tested by enzyme immunoassay. Changes in the proportion of all-cause gastroenteritis hospitalizations due to rotavirus pre- (July 2009-June 2012) and post-vaccine introduction (July 2012-June 2016) were compared using chi-square test. RESULTS: The proportion of acute gastroenteritis hospitalizations due to rotavirus among children <5 years of age significantly declined by 42% from a pre-vaccine median of 50% (343/684) to a post-vaccine median of 29% (118/396) (p < 0.001). The age distribution of rotavirus hospitalizations shifted toward older ages with 64% (759/1197) of rotavirus hospitalizations occurring in children <12 months of age pre-vaccine introduction to 47% (212/453) occurring in children <12 months of age post-vaccine introduction (p < 0.001). DISCUSSION: The decline in rotavirus hospitalizations following rotavirus vaccine introduction have been sustained over the first 4 years of the vaccination program in Ghana. Continued vaccination against rotavirus will ensure that this burden remains low.

Rotavirus strain distribution in Ghana pre- and post- rotavirus vaccine introduction.

BACKGROUND: Ghana introduced the monovalent rotavirus vaccine (Rotarix) into its national paediatric vaccination programme in May2012. Vaccine introduction was initiated nationwide and achieved >85% coverage within a few months. Rotavirus strain distribution pre- and post-RV vaccine introduction is reported. METHODS: Stool samples were collected from diarrhoeic children <5 years of age hospitalized between 2009 and 2016 at sentinel sites across Ghana and analyzed for the presence of group A rotavirus by enzyme immunoassay. Rotavirus strains were characterized by RT-PCR and sequencing. RESULTS: A total of 1363 rotavirus EIA-positive samples were subjected to molecular characterization. These were made up of 823 (60.4%) and 540 (39.6%) samples from the pre- and post-vaccine periods respectively. Rotavirus VP7 genotypes G1, G2 and G3, and VP4 genotypes P[6] and P[8] constituted more than 65% of circulating G and P types in the pre-vaccine period. The common strains detected were G1P[8] (20%), G3P[6] (9.2%) and G2P[6] (4.9%). During the post-vaccine period, G12, G1 and G10 genotypes, constituted more than 65% of the VP7 genotypes whilst P[6] and P[8] made up more than 75% of the VP4 genotypes. The predominant circulating strains were G12P[8] (26%), G10P[6] (10%) G3P[6] (8.1%) and G1P[8] (8.0%). We also observed the emergence of the unusual rotavirus strain G9P[4] during this period. CONCLUSION: Rotavirus G1P[8], the major strain in circulation during the pre-vaccination era, was replaced by G12P[8] as the most predominant strain after vaccine introduction. This strain replacement could be temporary and unrelated to vaccine introduction since an increase in G12 was observed in countries yet to introduce the rotavirus vaccine in West Africa. A continuous surveillance programme in the post-vaccine era is necessary for the monitoring of circulating rotavirus strains and the detection of unusual/emerging genotypes.

Autoimmune Pancreatitis Type 2: Case Report.

A middle-aged man presents with acute pancreatitis of unknown etiology and is found to have a presentation consistent with the diagnosis of type 2 autoimmune pancreatitis (AIP). AIP is a group of rare heterogeneous diseases that are challenging to diagnose. There are 2 types of AIP. Type 1 disease is the more common worldwide than type 2 AIP. While type 1 AIP is associated with IgG4-positive antibodies, type 2 AIP is IgG4 antibody negative. Both types of AIP are responsive to corticosteroid treatment. Although type 1 AIP has more extrapancreatic manifestations and more commonly relapses, this is a case of a patient with type 2 AIP with inflammatory bowel disease and relapsing course.

Stunting is associated with poor outcomes in childhood pneumonia.

OBJECTIVE: Stunting affects 26.7% of children worldwide, and little is known about its effects on the outcomes of childhood pneumonia. We evaluated the effect of stunting on the outcomes of pneumonia among children enrolled in two large clinical trials. METHODS: We analysed data from two WHO and USAID-sponsored inpatient treatment trials, the Severe Pneumonia Evaluation Antimicrobial Research study (n = 958) and the Amoxicillin Penicillin Pneumonia International Study (n = 1702), which enrolled children aged 2-59 months across 16 sites in LMICs. We assessed the effect of stunting (height-for-age Z score < -2) on treatment outcome and time to resolution of hypoxaemic pneumonia. RESULTS: Among 2542 (96%) children with valid data for height, 28% were stunted and 12.8% failed treatment by 5 days. The failure rate among stunted patients was 16.0% vs. 11.5% among non-stunted patients [unadjusted RR = 1.24 (95% CI 1.08, 1.41); adjusted RR = 1.28 (95% CI 1.10, 1.48)]. An inverse relationship was observed between height and failure rates, even among non-stunted children. Among 845 patients with hypoxaemic pneumonia, stunting was associated with a lower probability of normalisation of respiratory rate [HR = 0.63 (95% CI 0.52, 0.75)] and oxygen saturation [HR = 0.74 (95% CI 0.61, 0.89)]. CONCLUSIONS: Stunting increases the risk of treatment failure and is associated with a longer course of recovery in children with pneumonia. Strategies to decrease stunting may decrease the burden of adverse outcomes in childhood pneumonia in low-resource settings.

Etiology of bacteremia in young infants in six countries.

BACKGROUND: Neonatal illness is a leading cause of death worldwide; sepsis is one of the main contributors. The etiologies of community-acquired neonatal bacteremia in developing countries have not been well characterized. METHODS: Infants <2 months of age brought with illness to selected health facilities in Bangladesh, Bolivia, Ghana, India, Pakistan and South Africa were evaluated, and blood cultures taken if they were considered ill enough to be admitted to hospital. Organisms were isolated using standard culture techniques. RESULTS: Eight thousand eight hundred and eighty-nine infants were recruited, including 3177 0-6 days of age and 5712 7-59 days of age; 10.7% (947/8889) had a blood culture performed. Of those requiring hospital management, 782 (54%) had blood cultures performed. Probable or definite pathogens were identified in 10.6% including 10.4% of newborns 0-6 days of age (44/424) and 10.9% of infants 7-59 days of age (39/358). Staphylococcus aureus was the most commonly isolated species (36/83, 43.4%) followed by various species of Gram-negative bacilli (39/83, 46.9%; Acinetobacter spp., Escherichia coli and Klebsiella spp. were the most common organisms). Resistance to second and third generation cephalosporins was present in more than half of isolates and 44% of the Gram-negative isolates were gentamicin-resistant. Mortality rates were similar in hospitalized infants with positive (5/71, 7.0%) and negative blood cultures (42/557, 7.5%). CONCLUSIONS: This large study of young infants aged 0-59 days demonstrated a broad array of Gram-positive and Gram-negative pathogens responsible for community-acquired bacteremia and substantial levels of antimicrobial resistance. The role of S. aureus as a pathogen is unclear and merits further investigation.

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

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

International variations in bronchial responsiveness in children: findings from ISAAC phase two.

RATIONALE: Bronchial responsiveness is an objectively measurable trait related to asthma. Its prevalence and association with asthma symptoms among children in many countries are unknown. OBJECTIVES: To investigate international variations in bronchial responsiveness (BR) and their associations with asthma symptoms and atopic sensitization. METHODS: Bronchial challenge tests were conducted in 6,826 schoolchildren (aged 8-12 years) in 16 countries using hypertonic (4.5%) saline. FEV(1) was measured at baseline and after inhalation for 0.5, 1, 2, 4, and 8 min. BR was analyzed both as a dichotomous (bronchial hyperreactivity, BHR, at least 15% decline in FEV(1)) and as a continuous variable (time-response slope, BR slope, individual decline in FEV(1) per log(min)). RESULTS: Prevalence of wheeze last year ranged from 4.4% in Tirana (Albania) to 21.9% in Hawkes Bay (New Zealand) and of BHR from 2.1% in Tirana to 48% in Mumbai (India). The geometric mean BR slope varied between 3.4%/log(min) in Tirana and 12.8%/log(min) in Mumbai and Rome (Italy). At the individual level, BHR was positively associated with wheeze during the past 12 months both in affluent countries (OR = 3.6; 95% CI: 2.7-5.0) and non-affluent countries (OR = 3.0; 1.6-5.5). This association was more pronounced in atopic children. There was a correlation (rho = 0.64, P = 0.002) between center-specific mean BR slope and wheeze prevalence in atopic, but not in non-atopic children. CONCLUSIONS: BR to saline in children varied considerably between countries. High rates of BR were not confined to affluent countries nor to centers with high prevalences of asthma symptoms. The association between wheeze and BHR at the individual level differed across centers and this heterogeneity can be largely explained by effect modification by atopy. Pediatr. Pulmonol. 2010; 45:796-806. (c) 2010 Wiley-Liss, Inc.

Seroprevalence of west nile virus in ghana.

The epidemiology of West Nile virus (WNV) in Ghana, sub-Saharan Africa, and its relevance to transfusion were newly assessed. A total of 1324 plasma samples from five Ghanaian populations, including 529 children (<6 y old, pre-transfusion) and 795 adults (236 blood donors, 226 HIV-infected or non-infected pregnant women, 203 HIV symptomatic patients, and 130 AIDS patients) were screened for WNV RNA. No WNV RNA was detected, but 4.8% (13/271) and 27.9% (127/455) carried specific IgG in children and adults, respectively, and 2.4% (4/167) of the children had IgM. The prevalence of IgG antibody to WNV increased progressively and peaked around 30% between ages 1 and 30 y, then stabilized. The absence of viremia in four WNV IgM-positive children, and of reactivation in HIV-infected patients suggests that once host immunity is established, it appears to be robust. In addition, there were no clinical reports of WNV infection in the hospital in Kumasi, Ghana, suggesting that WNV epidemiology in Ghana differs from that seen in the U.S. Most infections occur early in life, and as the window for infection is quite short, the risk of transmission by transfusion appears to be low, and the risk of pathogenicity in immunocompetent recipients appears to be limited in an endemic area such as Ghana.

Exercise-induced bronchospasm and atopy in Ghana: two surveys ten years apart.

BACKGROUND: Asthma and allergic diseases have increased in the developed countries. It is important to determine whether the same trends are occurring in the developing countries in Africa. We aimed to determine the time trend in the prevalence of exercise-induced bronchospasm (EIB) and atopic sensitisation over a ten-year period in Ghanaian schoolchildren. METHODS AND FINDINGS: Two surveys conducted using the same methodology ten years apart (1993 and 2003) among schoolchildren aged 9-16 years attending urban rich (UR), urban poor (UP), and rural (R) schools. Exercise provocation consisted of free running for six minutes. Children were skin tested to mite, cat, and dog allergen. 1,095 children were exercised in 1993 and 1,848 in 2003; 916 were skin tested in 1993 and 1,861 in 2003. The prevalence of EIB increased from 3.1% (95% CI 2.2%-4.3%) to 5.2% (4.3%-6.3%); absolute percentage increase 2.1% (95% CI 0.6%-3.5%, p < 0.01); among UR, UP, and R children EIB had approximately doubled from 4.2%, 1.4%, and 2.2% to 8.3%, 3.0% and 3.9% respectively. The prevalence of sensitisation had also doubled from 10.6%, 4.7%, and 4.4% to 20.2%, 10.3%, and 9.9% (UR, UP, and R respectively). Mite sensitisation remained unchanged (5.6% versus 6.4%), but sensitisation to cat and dog increased considerably from 0.7% and 0.3% to 4.6% and 3.1%, respectively. In the multiple logistic regression analysis, sensitisation (odds ratio [OR] 1.77, 95% CI 1.12-2.81), age (OR 0.88, 95% CI 0.79-0.98), school (the risk being was significantly lower in UP and R schools: OR 0.40, 95% CI 0.23-0.68 and OR 0.54, 95% CI 0.34-0.86, respectively) and year of the study (OR 1.73, 95% CI 1.13-2.66) remained significant and independent associates of EIB. CONCLUSIONS: The prevalence of both EIB and sensitisation has approximately doubled over the ten-year period amongst 9- to 16-year-old Ghanaian children irrespective of location, with both EIB and atopy being more common among the UR than the UP and R children.