Effectiveness of ampicillin and combination of penicillin and chloramphenicol in the treatment of pneumonias: randomized controlled trial.

OBJECTIVE: To assess the effectiveness of ampicillin and a combination of benzyl penicillin and chloramphenicol in the treatment of pneumonias. DESIGN: Randomized controlled trial. SETTING: Tertiary care hospital. SUBJECTS: Patients 5 months to 4 years old with pneumonias of < 2 weeks duration. Exclusion criteria included acute bronchiolitis, allergy to penicillin, postmeasles pneumonia or prior administration of trial antibiotics in full dose for more than 2 days. INTERVENTION: Patients were randomized to receive either ampicillin (100 mg/kg/day) or combination of benzyl penicillin (100,000 units/kg/day) and chloramphenicol (100 mg/kg/day). The outcome measure was cure rate. RESULTS: There were 52 and 49 patients in the ampicillin and the combination groups, respectively. There was no significant difference in the baseline characteristics between groups except, nasal flare and cyanosis which were less in benzyl penicillin plus chloramphenicol group. There was also no difference either in the primary outcome, cure rate or secondary outcomes (days for cure, duration of tachypnea, fever and grunt) in the two. CONCLUSION: Considering the potential toxicity of chloramphenicol and the number of injections and doses to be given for the combination, ampicillin as a single drug could be preferred for the treatment of pneumonias, in this part of the country.

Missed opportunities for immunization in children under 2 years attending an urban teaching hospital.

A cross-sectional survey was done to assess the missed opportunity for immunization (MOI) in children under two years of age attending Medical Outpatient, Newborn Follow-up Service and Immunization Clinic of Institute of Child Health and to evaluate interventions. Baseline survey phase-I was done and two interventions: (i) education and awareness of immunization among health personnel; and (ii) attaching immunization slip to the outpatient form were done. After each intervention phase-II and phase-III surveys were carried out. The data from the different phases were analyzed for the effect of interventions. The total number of children surveyed were 634; 423 from Medical Outpatients, 108 from Newborn Follow-up Service and 103 from immunization Clinic. MOI was 35.5%, 23.1% and 9.7% in the above health facilities, respectively. After intervention I, the MOI was 24.5% and 12.2% in Medical Outpatient and Newborn Follow-up Service and none in Immunization Clinic. After intervention-II there was an improvement in immunization of 18.4%, 30.4% and 16.0% in the three health facilities mentioned above. MOI was avoided because the medical officers advised immunization in the above children. The difference in the MOI among Medical Outpatient and Immunization Clinic between baseline, phase-I and phase-II were significant (p < 0.001). It is concluded that MOI can be brought down by creating awareness periodically and that attaching an immunization schedule to the outpatient forms is an effective method of reducing MOI.

Etiological agents of acute poliomyelitis in south India.

This study was done to identify the specific etiological agents that cause acute poliomyelitis (APM). All the children newly diagnosed clinically as APM at the Institute of Child Health, Madras, during the period May 1988 to May 1989 were recruited. Stool specimen collection, transportation and identification of viruses by culture were done by standard procedures. The total number of children recruited was 312. Specimens were contaminated/insufficient in 10. Analysis was done for 302 cases. Polio virus type II was identified in 25.5% children, type I in 18.5%, type III in 15.9%, multiple polioviruses in 6.3% and non-polio enteroviruses (NPEV) in 20.2% cases. No virus was identified in 13.6%. Among the APM cases clinically diagnosed, the proportion of NPEV has increased considerably from 5% in 1984 to 20.2% in 1988-89. The age distribution was not significantly different between polio viruses and NPEV. The distribution of polio viruses and NPEV did not differ significantly in relation to immunization status, source of water supply, method of excreta disposal and the clinical types. For surveillance and control/eradication program of poliomyelitis, laboratory confirmation is essential.

Measles associated diarrhea and pneumonia in south India.

A prospective study was undertaken from April 1988 to April 1989, to assess the diarrheal and respiratory complications of measles. Standard definitions were used for the cases, Measles Associated Diarrhea (MAD) and Measles Related Pneumonia (MRP). Children with diarrhea not related to measles were recruited for comparison for MAD. There was a total of 454 cases, measles 53 (11.7%), measles associated diarrhea (MAD) 113 (24.9%), measles related pneumonia (MRP) 186 (41.0%) and MAD with MRP 102 (22.5%). Children under 10 months and 24 months were 11% and 51.5%, respectively. Altogether 215/401 (53.6%) and 288/401 (71.8%) had diarrhea and pneumonia. Children who had been measles vaccinated were 8.4%. The overall case fatality was 4.2%. Case fatality in pneumonia was 1.1%. There was no statistically significant difference between the MAD and diarrhea in relation to religion, water supply, the method of excreta disposal, nutritional status and immunization status other than measles vaccination. There was significant difference in the nature of stools between the two groups, the stools of MAD were more of dysenteric in nature (p < 0.005). Vitamin A deficiency as evidenced by eye signs, was significantly more in MAD than in diarrhea (p < 0.001). It is recommended that Vitamin-A be given to all children with measles, complication due to diarrhea be promptly and adequately treated and to consider measles vaccination earlier than 9 months.

Bacterial meningitis: diagnosis by latex agglutination test and clinical features.

To know the usefulness of Latex Agglutination Test (LAT) for the diagnosis of bacterial meningitis (BM), it was performed in all the 114 consecutive samples of CSF with polymorphs from 114 prospectively recruited children aged 2 months to 11 years. Definite diagnosis of BM based on culture and/or LAT was evident in 55. Among the 46 LAT positive, culture was positive in 3 only. Major organisms identified by LAT were H. influenzae B (HiB) in 28 and S. pneumoniae (SP) in 15. Ninety per cent of HiB and 67% of SP bacterial meningitis were under one year of age. Fever > 7 days prior to admission was not uncommon (38%) and 26% had received prior antibiotics. Meningeal signs were present in 64%. CSF cells were < 500/mm3 in 24% and sugar was > 50% of blood level in 23%. There was no significant difference in the immediate outcome between HiB and SP meningitis. The case fatality was 22% and was significantly high in cases who had altered level of consciousness on admission (p = 0.02). It is concluded that LAT is very useful for rapid diagnosis of BM.

Intramuscular injection as a provoking factor for paralysis in acute poliomyelitis. A case control study.

In order to identify the role of intramuscular injection (IM) as a provoking factor for poliomyelitis, a case control study as done at the Institute of Child Health, Madras from May 1988 to May 1989. The case was defined as acute poliomyelitis if he had acute asymmetric flaccid paralysis of lower motor neurone type without objective sensory disturbance following a short episode of fever. Controls were taken from children attending outpatient department for fever. Two controls matched for aged and sex were recruited for each case. Recruitment, data collection and clinical examination were done by a single pediatrician. IM injection received within 30 days prior to onset of paralysis or illness was considered to be the risk factor. The total number of cases and controls recruited were 257 and 515, respectively. Among cases, 172 (66.9%) out of 257 and among controls 252 (48.9%) out of 515, received IM injection within one month earlier to onset of paralysis or illness. The overall risk of paralysis, estimated for IM injection, was increased [odds ratio (OR) 2.1 (95% CI, 1.5-3.0)]. The maximum risk for paralysis was observed to be 2 weeks preceding the illness; the ORs for < 7 days was 2.2 (95% CI, 1.6-3.2) and for 7-13 days 3.2 (95% CI, 1.8 to 5.8). The risk of paralysis associated with IM injection was similar for unimmunized and immunized cases (OR 2.4 and 2.2). Multiple injections were not associated with a higher risk of developing paralysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for persistent diarrhea among children under 2 years of age. Case control study.

A case control study was done at the Institute of Child Health, Madras, among prospectively recruited children aged 1-23 months to identify the risk factors for persistent diarrhea. Cases were children with diarrhea persisting for > 14 days. Controls were children with acute diarrhea who had recovered within 7 days. Two controls for each case, matched for age were recruited. The total number of cases and controls recruited were 170 and 340. Fifteen risk factors for association with persistent diarrhea were studied. When the factors were adjusted for covariables by logistic regression, only 6 factors were found to be significant, namely, malnutrition (OR 2.9; 95% CI 1.9-4.5), dysenteric stools (OR 2.4; 95% CI 1.3-4.3), indiscriminate use of antimicrobials (OR 2.4; 95% CI 1.6-3.9), associated illnesses (OR 2.1; 95% CI 1.5-3.1), stools > 10/day (OR 1.8; 95% CI 1.2-2.8) and persistence of dehydration (OR 1.4; 95% CI 1.2-1.7). However, when invasive diarrhea was excluded, weight loss during study period became a significant factor. It is concluded that all children with acute diarrhea should be investigated for associated illnesses and treated adequately, indiscriminate use of antimicrobials should be avoided and nutritional support should be provided.

Risk factors for fatal pneumonia: a case control study.

We conducted a case control study to identify the risk factors for death among hospitalized children with acute pneumonia at the Institute of Child Health, Madras. All the 70 patients who died of pneumonia constituted the case--patients and 140 children recovered from pneumonia, selected by systematic sampling, during the same period served as controls. By univariate analysis, the risk factors for death in pneumonia observed were associated illnesses--Odds Ratio (OR) 22.2. (95% confidence interval [CI] 9.8-51.4; p = < 0.001); congenital anomalies--OR 10.4 (2.9-37.8; p = < 0.001); severe pneumonia--OR 4.2 (1.2-14.4; p = 0.09); marasmic status--OR 2.9 (1.5-5.7; p = 0.001); age under 6 months--OR 2.8 (1.3-5.7; p = 0.004); and severity of the pneumonia (lobar versus segmental)--OR 2.0 (0.9-4.5; p = 0.09). By logistic regression analysis the following risk factors were significant--associated illnesses. (51.6; 18-146.9; p = < 0.001); age under 6 months (6.5; 2-20.6; p = < 0.001), marasmic status (5.8; 2.2-15.6; p = < 0.001); and congenital anomalies (3.8; 2.0-7.1; p = < 0.001). These risk factors should be kept in mind by the clinicians for appropriate intervention at an earlier stage to minimize death.

Epidemiological and clinical features of acute poliomyelitis children admitted in an urban hospital.

Six hundred and fourteen acute poliomyelitis children (57% boys) admitted to the Institute of Child Health, Madras, during January 1988 to September 1989 were studied. Diagnosis was based on clinical grounds. The age ranged from 2 months to 75 months. Residents of Madras city area were 31%, the rest being from neighbouring district (55%) and states (14%). Only 24% got protected water supply and 26% had access to safe disposal of excreta. Only a quarter (26.4%) had been immunized with 3 or more doses of oral polio vaccine. Intramuscular injection was given in 70% within one month of onset of paralysis. The commonest presentation was spinal form (80%) followed by spinobulbar (18%) and bulbar form (2%). Paralysis was severe in 72%, moderate in 6% and mild in 22%. Case fatality was 3.3%. The age at paralysis and clinical features in India have not changed over years. We conclude that the immunization programme should be effectively implemented to the maximum efficiency especially for the poor/illiterate community. Clinicians must be educated to avoid unwarranted intramuscular injections for any febrile illness.

Acute poliomyelitis in children: comparison of epidemiological and clinical features among immunized, partially immunized and unimmunized.

This study was conducted to compare the epidemiological and clinical features of acute poliomyelitis among immunized, partially immunized and unimmunized, as these have been postulated to be different amongst these subgroups. Of 614 children with acute poliomyelitis admitted at the Institute of Child Health, Madras, 162 (26.4%) were immunized, 183 (29.8%) were partially immunized and 269 (43.8%) were unimmunized. Poor environmental sanitation, unprotected water source and parental illiteracy were significantly more common among unimmunized group compared to the immunized group. It is concluded that there is no significant difference in symptoms, signs, clinical types, severity of paralysis and case fatality between the immunized, partially immunized and unimmunized.

Neonatal tetanus: observations on antenatal immunization, natal and immediate post-natal factors.

The objective is to study the present status of the antenatal immunization with tetanus toxoid and the natal and immediate postnatal factors among the cases of neonatal tetanus and the changes over time. Retrospective analysis of 61 case records of Neonatal Tetanus (NNT) during 1987-88 and prospective study of 19 cases of 1989 was done. The number of cases have decreased considerably from 88 in 1984 to 19 in 1989. 80% of cases were from residents outside the city. Antenatal checkup improved from 37.7% in 1987 to 73.7% in 1989. The proportion of mothers of NNT cases who received = greater than 2 doses have increased from 19.7% in 1987-88 to 31.6% in 1989. In the year 1989, 21% and 10.5% have received the I and II doses of TT respectively at the 9th month of pregnancy, the value of which is doubtful. Majority (73.7%) were domiciliary deliveries conducted by dhais and this has not changed over the years. The importance of antenatal booking, immunization at the appropriate time, hygienic obstetric and cord care are stressed.

Potency of oral polio vaccine stored at distribution centers in Madras.

This study was done with the objective to measure, monitor, and document the potency of oral polio vaccine and the storage conditions in the city of Madras for a period of one year from May 88. The Corporation of Madras which takes care of indenting and supplying the vaccine has 87 centers for storage and distribution. We took 12 samples a month from these centers by stratified random sampling technique adopting proportionate sampling. The samples were coded and sent to the laboratory. The investigator noted the storage conditions in a specially designed data card. Results were notified to the managers concerned. 122 samples were tested out of which 28 (23%) showed loss of potency (less than log 10(5.84]. The loss of potency is statistically significant in centers not having dial thermometer and where inappropriate carrier was used for transport of vaccine. It was least in Maternity and Child Health Centers probably due to the orientation of the personnel. The frequency of loss of potency was more in the beginning of the study and decreased as the study progressed. Monitoring of storage conditions and potency of vaccine along with periodic training and reorientation of health personnel are stressed.

Age for measles immunization seroconversion after measles vaccination at 6-8 months of age--a randomized controlled trial.

The objective of the study was to compare the effectiveness of measles vaccine by seroconversion in vaccinated children with non-vaccinated children of 6 to 8 months age group in a city slum community so as to study the feasibility of advancing the age of immunization. Live attenuated lyophilized Schwartz strain of measles vaccine was used. Hemagglutination inhibition (HI) antibody was estimated. Seroconversion was defined as either the conversion of negative to positive or a two fold rise in titre. One hundred and thirty two children completed the study. There was no difference in the age, sex and nutritional status between vaccinated and non-vaccinated groups (p greater than 0.7). The seroconversion rate in the vaccinated group was 65% and in the non-vaccinated group was 26%. The age, sex and nutritional status did not significantly affect the seroconversion. Our data suggest that immunization with measles vaccine may be effective as early as 6 months of age. Immunization at 6 months may be needed at least for children in densely populated areas like cities and towns.

Prevalence of placentally transmitted antibodies for measles in infants 3 to 11 months old in an urban slum community.

Upto 35% of infants aged between 6 and 11 months are infected with measles in India with its associated high morbidity and mortality. The objective of the study is to know the waning pattern of placentally transmitted antibodies (PTA) for measles so that the age at which children are likely to become susceptible to measles infection could be identified. A cross-sectional serological survey of children aged 3 to 11 months in one of the Integrated Child Development Service (ICDS) area in Madras city slums was done. Venous blood from 376 children was collected and was tested for Hemagglutination Inhibition (HI) antibodies by standard microtitration technique. Titre greater than or equal to 1:8 has been considered as protective. The proportion of children with immune level and the Geometric Mean Titre (GMT), declined to the least by 5 months which denotes that most of the infants become susceptible to measles infection from as early as 5 months of age. There is no significant difference in the waning pattern between different age groups, sex and nutritional status. A community study for effectiveness of measles vaccine at 6-8 months of age is needed to know the feasibility of immunization earlier than 9 months of age.