Effectiveness of 13-valent pneumococcal conjugate vaccine on radiological primary end-point pneumonia among cases of severe community acquired pneumonia in children: A prospective multi-site hospital-based test-negative study in Northern India.

INTRODUCTION: Community acquired pneumonia (CAP) is a leading cause of under-five mortality in India and Streptococcus pneumoniae is the main bacterial pathogen for it. Pneumococcal Conjugate Vaccine 13 (PCV13) has been introduced in a phased manner, in the national immunization program of India since 2017/2018. The primary objective of this study was to evaluate the effectiveness of PCV13 on chest radiograph (CXR)-confirmed pneumonia, in children hospitalized with WHO-defined severe CAP. METHODS: This prospective, multi-site test-negative study was conducted in a hospital-network situated in three districts of Northern India where PCV13 had been introduced. Children aged 2-23 months, hospitalized with severe CAP and with interpretable CXR were included after parental consent. Clinical data was extracted from hospital records. CXRs were interpreted by a panel of three independent blinded trained radiologists. Exposure to PCV13 was defined as ≥2 doses of PCV13 in children aged ≤ 12 months and ≥ 1 dose(s) in children > 12 months of age. Our outcome measures were CXR finding of primary endpoint pneumonia with or without other infiltrates (PEP±OI); vaccine effectiveness (VE) and hospital mortality. RESULTS: From 1st June 2017-30th April 2021, among 2711 children included, 678 (25.0%) were exposed to PCV1. CXR positive for PEP±OI on CXR was found in 579 (21.4%), of which 103 (17.8%) were exposed to PCV. Adjusted odds ratio (AOR) for PEP±OI among the exposed group was 0.69 (95% CI, 0.54-0.89, p = 0.004). Adjusted VE was 31.0% (95% CI: 11.0-44.0) for PEP±OI. AOR for hospital mortality with PEP±OI was 2.65 (95% CI: 1.27-5.53, p = 0.01). CONCLUSION: In severe CAP, children exposed to PCV13 had significantly reduced odds of having PEP±OI. Since PEP±OI had increased odds of hospital mortality due to CAP, countrywide coverage with PCV13 is an essential priority.

Erratum to "Perceptions and practices of COVID-19 protective measures among the general public of North India" [Clin Epidemiol Glob Health 13 (2022) 100927].

[This corrects the article DOI: 10.1016/j.cegh.2021.100927.].

Perceptions and practices of COVID-19 protective measures among the general public of North India.

BACKGROUND: India has a high COVID-19 burden. The Indian government responded to the pandemic by mandating its population to adhere to certain Protective Measures (PMs). Compliance to these PMs depends on their acceptability and adaptability among the general public. AIMS: To explore the perceptions and practices of COVID-19 related PMs among the general public of North India. METHODS: Qualitative study in four administrative districts (Lucknow, Etawah, Patna and Darbhanga) of North India. Two urban and two rural districts were purposefully selected. Audio in-depth interviews (IDIs) were conducted with healthy caregivers of children (2-59 months). Data was managed using Atlast Ti and analyzed using conventional content analysis. RESULTS: From July-Sep 2020, 60 IDIs were conducted; 36.6% (22/60) were females and 26.6% (16/60) had below primary education. Respondents concurred that most people in their society flouted the recommended PMs. The reasons for poor/non-compliance with PMs were: perceived poor susceptibility to illness, perceived less severity of COVID-19 and low perceived benefits of complying with the PMs. Respondents opined that COVID-19 is less prevalent in rural areas and among the educated population. Most respondents were aware of the recommended PMs and opined that these must be followed, however subjective norms, social norms and behavioral intentions negatively impacted compliance. CONCLUSIONS: Since there was poor community perception of susceptibility to COVID-19 as well as poor perceived severity, the community did not understand the benefits of adhering to the recommended PMs. Therefore, future health communication strategies must take these into account to increase the possibility of success.

Epidemiology of Hypoxic Community-Acquired Pneumonia in Children Under 5 Years of Age: An Observational Study in Northern India.

BACKGROUND: Community-acquired pneumonia (CAP) is the leading cause of under-five mortality in India. An increased risk of mortality has been reported in cases of hypoxic pneumonia. METHODS: The primary objective of this study was to assess the proportion of children aged 2-59 months, hospitalized with hypoxic CAP, as well as socio-demographic, clinical, and radiological features associated with it. The secondary objective was to determine the risk of mortality among hospitalized cases of hypoxic CAP. This prospective, observational study was conducted in four districts of Northern India, between January 2015 and April 2021. A hospital-based surveillance network was established. Inclusion criteria were as follows: (a) child between 2 and 59 months, (b) hospitalization with symptoms of WHO-defined CAP, (c) resident of project district, (d) illness of <14 days, and (e) child had neither been hospitalized for this illness nor recruited previously. Children whose chest x-rays (CXRs) were either unavailable/un-interpretable and those that received any dose of pneumococcal conjugate vaccine-13 were excluded. Hypoxic pneumonia was defined as oxygen saturation <90% on pulse oximetry or requiring oxygen supplementation during hospital stay. RESULTS: During the study period, 71.9% (7,196/10,006) children of severe pneumonia were eligible for inclusion, of whom 35.9% (2,580/7,196) were having hypoxic pneumonia. Female gender and use of biomass fuel for cooking increased the odds of hypoxic CAP. Clinical factors like wheezing, pallor, tachypnea, low pulse volume, presence of comorbidity, general danger signs, severe malnutrition, and radiological finding of primary end-point pneumonia ± other infiltrates (PEP±OI) also increased the odds of hypoxic CAP in a conditional logistic regression model. Adjusted odds ratio for mortality with hypoxia was 2.36 (95% CI: 1.42-3.92). CONCLUSION: Almost one-third of cases hospitalized with severe CAP had hypoxia, which increased chances of mortality. Besides known danger signs, certain newer clinical signs such as pallor and wheezing as well as PEP+OI were associated with hypoxic CAP. Therefore, objective assessment of oxygen saturation must be done by pulse oximetry in all cases of CAP at the time of diagnosis.

Chest radiograph findings in children aged 2-59 months hospitalised with community-acquired pneumonia, prior to the introduction of pneumococcal conjugate vaccine in India: a prospective multisite observational study.

OBJECTIVES: The current study was a hospital-based surveillance of cases hospitalised with WHO-defined community-acquired pneumonia in children aged 2-59 months, to assess the radiological abnormalities in chest X-rays and to identify the demographic and clinical correlates of specific radiological abnormalities, in residents of prespecified districts of Uttar Pradesh and Bihar, India. DESIGN: Prospective, active, hospital-based surveillance. SETTING: Multisite study conducted in a network of 117 secondary/tertiary care hospitals in four districts of Uttar Pradesh and Bihar, India. PARTICIPANTS: Included were children aged 2-59 months, hospitalised with community-acquired pneumonia, residing in the project district, with duration of illness <14 days and who had not been hospitalised elsewhere for this episode nor had been recruited previously. MAIN OUTCOME MEASURE: Concordant radiological abnormalities in the chest X-rays. RESULTS: From January 2015 to April 2017, 3214 cases were recruited and in 99.40% (3195/3214) chest X-rays were available, among which 88.54% (2829/3195) were interpretable. Relevant radiological abnormalities were found in 34.53% (977/2829, 95% CI 32.78 to 36.28). These were primary end point pneumonia alone or with other infiltrates in 22.44% (635/2829, 95% CI 20.90% to 23.98%) and other infiltrates in 12.09% (342/2829; 95% CI 10.88% to 13.29%). There was a statistically significant interdistrict variation in radiological abnormalities. Statistically significantly higher proportion of abnormal chest X-rays were found in girls, those with weight-for-age z-score ≤-3SD, longer duration of fever, pallor and with exposure to biomass fuel. CONCLUSIONS: Among hospitalised cases of community-acquired pneumonia, almost one-third children had abnormal chest radiographs, which were higher in females, malnourished children and those with longer illnesses; and an intra-district variation was observed.