Pneumonia in children below the age of five and their mothers

Convener: Rune Andersson, Department of infectious Diseases, The Sahlgrenska Academy, University of Gothenburg

Contact: rune.andersson@gu.se

Pneumonia is the leading cause of death in children between 1 month and five years of age in low- and middle income countries. Pneumonia killed an estimated 935, 000 children under the age of five in 2013, accounting for 15% of all deaths of children in this age group. Pneumonia affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa.

Pneumococci are leading bacterial cause of pneumonia. A conjugate vaccine is included in the childhood vaccination programs in many countries since a few years with need of evaluation of the effect. 

Around 3 billion people cook and heat their homes using solid fuels (i.e. wood, charcoal, coal, dung, crop wastes) on open fires or traditional stoves. This produce high levels of household (indoor) air pollution (HAP) which includes a range of health damaging pollutants such as fine particles and carbon monoxide. Globally, indoor air pollution is responsible for 1.6 million deaths due to pneumonia, chronic respiratory disease and lung cancer. The women involved in the cooking and their children are in particular exposed.

To reduce the burden of respiratory diseases multi-professional interventions are needed, which will be presented in the panel:

• Implementation of childhood vaccinations, better nutrition, breastfeeding
• Reducing indoor air pollution with better stoves, improved ventilation and other architectural interventions
• Changes in cooking that are acceptable according to anthropological aspects
• Reduced tobacco smoking
• Reduced outdoor air pollution from traffic, factories, heating

To the panel we invite persons with knowledge and experience in architecture, atmosphere science, occupational health, environmental medicine, child health, infectious diseases, microbiology, anthropology and other relevant research areas.

23 Aug., 16:00–17:30, Seminar Room Y11

• The burden of pathogenic microbes in Congolese children. Susann Skovbjerg, University of Gothenburg.
• Effectiveness of biogas in reducing household air pollution and child pneumonia in Nepal. Sharat C Verma, University of California.
• Effects of household air pollution on airway symptoms in women cooks in Ethiopia. Mona Lärstad, University of Gothenburg.
• High antibiotic use and increasing rates of penicillin non-susceptible pneumococci in Tanzanian children after the vaccine introduction. Matilda Emgård, University of Gothenburg.

Abstracts

The burden of pathogenic microbes in Congolese children. Susann Skovbjerg, University of Gothenburg.

One strategy to lower the disease burden and mortality in childhood pneumonia is the introduction of a pneumococcal vaccine to infants. In the Democratic Republic (D.R.) of Congo, a vaccine covering 13 out of 97 pneumococcal types was introduced in 2013, but there are no data on the pneumococcal types or the microbial load in Congolese children. We have sampled 795 healthy children attending seven Health Centers in the Kivu province of D.R. Congo, and will compare the carriage of bacteria and viruses, and the types and resistance patterns of pneumococci to those obtained from children hospitalized in Bukavu due to severe respiratory tract infections. New molecular biological methods are used, as well as traditional bacterial culture, with knowledge transfer to the local microbiological laboratory in Bukavu. Preliminary results show that 21% of healthy children carry pneumococci. Living in rural area, no occupation of parents, malnutrition, recent upper respiratory tract infections, current antibiotic use, and charcoal, dung or wood as cooking fuel increases the odds of carrying pneumococci, whereas the pneumococcal vaccine is protective. The portion of pneumococci non-susceptible against penicillins, macrolides and co-trimoxazole were high. The carriage rates in healthy children of other bacteria (such as Haemophilus influenzae and Bordetella pertussis) and viruses (such as rhino and enteroviruses) were also high with local variability between different sampling sites indicating local spread. Evaluation of pneumococcal vaccine effects and local resistance patterns for updating current treatment guidelines are crucial in combating childhood pneumonia in low-income countries.

Effectiveness of biogas in reducing household air pollution and child pneumonia in Nepal. Sharat C Verma, University of California.

Acute respiratory infection (ARI) is the primary cause of childhood morbidity, and acute lower respiratory infection (ALRI) or pneumonia is the leading cause of child mortality in Nepal. Household air pollution (HAP) from solid-fuel-burning stoves has been causally linked to ARI including ALRI in children. In Nepal, 83% of households use solid fuel for cooking and or heating. However, Nepal has been a pioneer among developing countries in aggressively promoting two biomass-based clean cookstove technologies: chimney biomass cookstove, and biogas using animal dung. Biogas consists of ~60% methane and burns cleanly, but, there has been no large-scale monitoring and evaluation conducted to assess their effectiveness in either reducing HAP or ALRI/pneumonia. Mobilizing community-based nurses--female community health volunteers(FCHVs), and using the World Health Organization's Integrated Management of Child Illness (WHO-IMCI) guidelines/questionnaire, we are actively monitoring the incidence of ARI and  ALRI in 547 children ≤ 36 months living in homes using biogas (n=284) or traditional non-chimney biomass cookstove (n=263) as the primary cookstove.  Using questionnaire, FCHVs are also documenting weekly fuel use pattern in children's home, and their food eating practices. They are also recording children's growth. On a quarterly basis, we are also measuring and documenting particulate matters (PM2.5) in the kitchen and child's sleeping area in 547 homes. This presentation seeks to share the protocol of this study and some preliminary findings.

Effects of household air pollution on airway symptoms in women cooks in Ethiopia. Mona Lärstad, University of Gothenburg.

Background: Around three billion people in low- and middle-income countries cook and heat their homes using solid fuels (i.e. wood, charcoal, coal, dung, crop wastes) on open fires or traditional stoves, which results in high levels of household air pollution (HAP). According to WHO, 4.3 million people a year die from the exposure HAP. Women, especially those responsible for cooking and their young children, are most heavily exposed. Exposure to HAP has been associated with e.g. chronic obstructive pulmonary disease (COPD), lung cancer, respiratory infections and eye diseases. Aim: To assess HAP and to determine the effects of HAP on airway symptoms as well as eye symptoms in women cooks in rural and urban areas of Ethiopia. Method: The study was carried out in 294 never-smoking women, aged 18-51 years, in March–April 2016. The study was conducted in two places: in the district of Butajira (n=177), located about 130 km from Addis Ababa, and in Addis Ababa (n=117). All women had small children and were responsible for cooking in their homes. A questionnaire with questions about respiratory symptoms and illnesses, nasal and eye symptoms, house and kitchen, fuel and stove etc. was used. Results: Of the women in Butajira the majority (99.4%) lived in single housing, and 100% used wood as the main fuel. In Addis Ababa 51.3% lived in multi-family housing and only 4.4% used wood and 54% used electricity. Regarding symptoms, 35.5% of the women in Butajira had cough the last 12 months, but only 24.4% in Addis Ababa (p=0.041). Phlegm was also more common in Butajira, 17.9% vs. 6.8% (p=0.007). Wheeze was more common in Butajira as well, 9.1% vs. 1.7% (p=0.010). Nasal symptoms (runny nose/congestion) without having a cold was more common in Butajira, 41.5% vs. 20.5% (p<0.001). Also, eye symptoms were increased in Butajira, 53.7% vs. 20.5% (p<0.001). Conclusions: HAP exposure is an important risk factor for airway symptoms and eye symptoms in women cooks. These symptoms are more common in the district of Butajira compared to Addis Ababa.

High antibiotic use and increasing rates of penicillin non-susceptible pneumococci in Tanzanian children after the vaccine introduction. Matilda Emgård, University of Gothenburg.

Background: The pneumococci is the most common cause of bacterial pneumonia in children under-five. The pneumococcal conjugate vaccine (PCV-13) was introduced in Tanzania December 2012. Before introduction, high rates of penicillin non-susceptible pneumococci (67.8%) were shown among healthy children in Dar es Salaam. Aim: To determine the rate of nasopharyngeal carriage and antibiotic susceptibility of pneumococci in children below 2 years of age in Moshi, Tanzania shortly after introduction of the conjugate vaccine. Method: The study was carried out in November 2013–April 2015, 775 children were sampled for pneumococcal carriage and their parents were questioned to obtain socio-demographic information. The samples were cultured for growth of pneumococci and antimicrobial susceptibility tests among the pneumococcal isolates were performed. Results: Out of the children 31.5% (244/775) were pneumococcal carriers. Pneumococcal carriage was positively related to age and current symptoms of upper respiratory tract infection and negatively related to recent antibiotic use (p-value <0.05). Antibiotic use in the children were high, 53.9% (418/775) of the children had been treated with antibiotics in the past 3 months. The most common antibiotic used in the children was amoxicillin. Antibiotic non-susceptibility was high in the pneumococcal isolates, 96.7% were non susceptible to Trimethoprim-Sulfamethoxazole. Notably, penicillin non-susceptibility had increased significantly during the years studied, from 31.0% in 2013, to 46.9% 2014 and 53.3% 2015. Conclusions: Despite introduction of the PCV-13, penicillin non-susceptible pneumococci increased among children in Moshi, Tanzania between 2013 and 2015. Over-use of antibiotics in children seems to be common in Moshi and might contribute to increased antibiotic resistance.