Childhood Pneumonia: What’s Unchanged, and What’s New?

Childhood pneumonia is still a significant clinical and public health problem. India contributes the highest number of deaths due to pneumonia, accounts for about 20% of global mortality among under five children. Various etiologic agents including bacteria, viruses and atypical organism are responsible for childhood pneumonia. Recent studies suggest that viruses are one of the major causes of childhood pneumonia. Among viruses, respiratory syncytial virus has got great attention and several recent studies are reporting it as an important organism for pneumonia. Lack of exclusive breast feeding during first six months, improper timing of start and content of complimentary feeding, anemia, undernutrition, indoor pollution due to tobacco smoking and use of coal and wood for cooking food and lack of vaccinations are important risk factors. X-ray chest is not routinely performed to diagnose pneumonia while use of lung ultrasound is increasing to detect consolidation, pleural effusion, pneumothorax and pulmonary edema (interstitial syndrome). Role of C-reactive protein (CRP) and procalcitonin is similar, to differentiate between viral and bacterial pneumonia, however duration of antibiotics is better guided by procalcitonin. Newer biomarkers like IL-6, presepsin and triggering receptor expressed on myeloid cells 1 are needed to be evaluated for their use in children. Hypoxia is significantly associated with childhood pneumonia. Therefore, use of pulse oximetry should be encouraged for early detection and prompt treatment of hypoxia to prevent adverse outcomes. Among the available tools for risk of mortality assessment in children due to pneumonia, PREPARE score is the best but external validation will be needed.

Role of MMP-1, MMP-8 and MMP-9 gene polymorphisms in preterm birth

Novel approaches to preterm births are underway building upon our prior discoveries and probing into unknown discovery pathways. The recent findings showed a high affinity of MMP-9 in serum and its polymorphisms for preterm birth. This study, which is a hospital-based case– control study, aims to investigate the association of MMP-1, MMP-8 and MMP-9 polymorphisms, and levels of MMP-9 in preterm birth. Increased level of MMP-9 was reported in cases as compared to control. The significant association of MMP-9 (-1562) CT (P = 0.001; OR = 1.44 (CI = 0.97–2.14)) and TT genotype (P = 0.05; OR = 2.6 (CI = 1.46–4.69)) were reported in preterm birth. Our findings suggest thattheMMP-9 plays an important role in contributing preterm labour and this can be used as a diagnostic tool during pregnancy

Effect of Different Doses of Inhaled Corticosteroids on the Isolation of Nasopharyngeal Flora in Children with Asthma

Objectives: To find the effects of inhaled corticosteroids and the impact of different doses ofinhaled corticosteroids on the isolation of nasopharyngeal flora in asthmatic children aged 1-15 years. Methods: The study included 75 children with asthma and 25 age-matchedcontrols. Nasopharyngeal swabs were obtained. Bacteria were identified by standardtechniques. Results: Pathogenic organisms were isolated from 36% of asthmatic childrenand 20% of controls, the difference was not significant statistically (OR=2.25, 95% CI=0.75-6.67, P=0.13). There was no statistically significant association of using a high dose ofinhaled corticosteroids with the isolation of pathogenic organisms. Usage of biomass fuel forcooking in the household of asthmatic children increases the risk of colonization (OR=3.4,95% CI= 1.26-9.10, P=0.03). Conclusion: Inhaled corticosteroids are safe in the treatmentof asthma and there is no association between different doses of Inhaled corticosteroids andisolation of the pathogenic organism.

Association of TLR4 and TNF-a Gene Polymorphisms and TLR4 mRNA Levels in Preterm Birth in a Northern Indian Population

Objective: To assess the association of TLR4 (rs4986790 and rs4986791) and TNF-α(rs1800629) genes polymorphisms and TLR4mRNA levels with preterm birth. Methods:Hospital-based case-control study on women of Caucasoid morphological subtype ethnicityin Northern India. Inclusion criteria for cases: women aged between 18-40 years with pretermbirth (<37 weeks gestation), and for controls: women who delivered a term neonateconsecutive to an enrolled case. Three polymorphisms TLR4 (Asp299 Gly, Thr399 Ill) andTNF-á (-308G/A) and TLR4 mRNA levels were compared between cases and controls.Results: From 2012-2015, 559 cases and 559 controls were recruited. TLR4 mRNA levelswere found to be higher (P<0.001) in cases [(0.7 (0.04)] than in controls [(0.5 (0.04)]. Noassociation was found between TLR4 Asp299 Gly, TLR4 Thr399 Ill and TNF-α (-308G/A)with preterm birth. Conclusion: Increased TLR4 mRNA levels seem to be associated withpreterm birth, and can be investigated further as a potential biomarker for identifying womenat risk

Safety and Immunogenicity of Two Doses of a Quadrivalent Meningococcal Polysaccharide Diphtheria Toxoid Conjugate Vaccine in Indian and Russian Children Aged 9 to 17 Months

Objective: Evaluation of tolerability, safety and immunogenicity ofa two-dose series of a quadrivalent meningococcalpolysaccharide diptheria toxoid conjugate (ACYW-D) vaccine inIndian and Russian infants/toddlers.Design: Open-label, single-arm, phase III multi-national trial.Study participants: 300 children aged 9-17 months, previouslyunvaccinated against meningococcal disease from four siteseach in India (n=200) and the Russian Federation (n=100).Intervention: Two 0.5 mL doses of ACYW-D by intramuscularinjection, 3-6 months apart.Main outcome measures: Meningococcal antibody titers toserogroups A, C, W-135 and Y, determined using a serumbactericidal assay in the presence of human complement beforevaccination and 28 days after the second vaccination. Titers ?1:8against either/all of the A, C, W-135 or Y were considered sero-protective.Results: After dose 2, 95.7–99.5% and 92.9–99.0% of infants/toddlers achieved seroprotection across the four serogroups inIndia and the Russian Federation, respectively. No immediateadverse events were reported after any dose of ACYW-D.Solicited reactions were reported in 49.2% of participants, andwere mainly of Grade 1 severity, and resolved within three days.Unsolicited adverse events were reported in 19.1% of infants:one event (Grade 3 diarrhea, resolving within one day) wasconsidered related to study vaccine. No non-serious adverseevents led to premature withdrawal from the study. Four seriousadverse events were reported; none were considered related tostudy vaccine. No deaths occurred during the study.Conclusions: A two-dose series of ACYW-D vaccine in Indianand Russian children (9-17 month) was well-tolerated with nosafety concerns, and induced robust bactericidal antibodyresponses against the meningococcal serogroups contained inthe vaccine

Recurrent benign copy number variants & issues in interpretation of variants of unknown significance identified by cytogenetic microarray in Indian patients with intellectual disability.

Background & objectives: Cytogenetic microarray (CMA) is now recommended as a first-tier clinical diagnostic test in cases with idiopathic intellectual disability and/or developmental delay (ID/DD). Along with clinically relevant variants, CMA platforms also identify variants of unknown significance (VUS). This study was done to look for utility and various issues in interpretation of copy number variants (CNVs) in Indian patients with ID/DD. Methods: The CMA was performed in 86 Indian patients with idiopathic ID/DD with or without dysmorphic features. CNV was reported if copy number gain was >400 kb in size and copy number loss was > 200 kb in size. Results: Pathogenic CNVs were found in 18 of 86 (20.9%) patients. One large (14 Mb size) de novo heterozygous copy number gain was found in one patient. VUS (total 31) were present in 17 of 86 (19.7%) patients. Five novel recurrent benign CNVs were also present in our patients. Interpretation & conclusions: Our findings highlight the difficulties in interpretation of CNVs identified by CMA. More Indian data on VUS and recurrent benign CNVs will be helpful in the interpretation of CMA in patients with ID/DD.

Molecular characterization of the rotavirus enterotoxin NSP4 gene of strains causing diarrhoea in children aged 0-5 years in northern India.

Non structural protein 4 (NSP4) gene of Rotavirus encodes a multifunctional protein which has significant role in viral multiplication and pathogenesis of acute watery diarrhoea associated with rotaviral gastroenteritis. It is known as the first viral enterotoxin and mutations of the gene have been linked to altered pathogenesis. This study was planned to ascertain the genotypes and genetic variations of NSP4 gene in the rotavirus strains prevalent in this area. We collected consecutive diarrhoeal stools from equal no of children aged under five years hospitalized with diarrhoea in a period from January 2010 to June 2012 and tested them for rotavirus antigen by ELISA. NSP4 gene was amplified by RT-PCR and subsequently sequenced (Big-Dye terminator kit using 3130 ABI, Genetic analyzer) and genotyped by Rotavirus C software. Of the 260 samples, 58(22.3%) samples were positive by ELISA. We were able to amplify NSP4 gene by RTPCR from 45 strains of which 35 amplicons were selected for sequencing. Total 25(71.4%) strains belonged to genotype E1, 6 (17.1%) strains to genotype E2 and 4 (11.4%) matched with the genotype E6. Sequence analysis revealed changes in the nucleotides causing punctate mutations in the conserved regions, the Inter species variable domain (ISVD) and the enterotoxin region (amino acid 114-135). On evolutionary analysis of 33 strains amino acid at position 131 was found under positive selection.

Energy and Protein Intake During Pregnancy in Relation to Preterm Birth: A Case Control Study.

Objective: To find the association of maternal energy and protein intake with preterm birth. Design: Case-control study. Setting: Two hospitals at Lucknow in Northern India. Participants: Cases (n=350) were defined as mothers (age 18-40 y) of singleton live preterm (<37 wks) neonates. Controls (n=350) were mothers who delivered a singleton neonate, consecutive to enrolled case, after completing 37 weeks of gestation. Results: There was a statistically significant lower mean (SD) energy intake [cases 1624 (249) Kcal vs. controls 1911 (341) Kcal; P<0.001] and protein intake [cases 32.1 (6.1) vs. controls 37.2 (7.0); P<0.001] among women who delivered preterm neonates. Maternal energy and protein intake had significant positive correlation with neonatal weight, length, foot length, head circumference and chest circumference. Conclusion: Lower energy and protein intake during pregnancy is possibly associated with preterm birth.

Salivary Cortisol Estimation to Assess Adrenal Status in Children with Fluid Unresponsive Septic Shock.

We evaluated the adrenal status by estimating baseline and ACTH stimulated salivary cortisol in 51 children with fluid unresponsive septic shock at 30 and 60 minutes, and basal salivary cortisol (9-11 am) in 79 healthy children. The baseline salivary cortisol (median,IQR) among patients (19.8, 7.2-42.4 nmol/L) was higher than healthy children (2.6, 1.3-7.6 nmol/L) (P=0.001). Non-survivors and those with catecholamine refractory shock had higher baseline cortisol level, though difference was statistically insignificant. Absolute adrenal insufficiency (baseline salivary cortisol <1.3nmol/L) was diagnosed in 8 (15.7%) patients. Relative adrenal insufficiency (rise in cortisol level above baseline value after stimulation <25nmol/L) was observed in 68.6% of all patients; 71.9% among non-survivors, and in 71.4% patients with catecholamine refractory shock. Salivary cortisol estimation appears to be feasible in children with septic shock. Relative adrenal insufficiency is common in these children.

Prospective multi-centre sentinel surveillance for Haemophilus influenzae type b & other bacterial meningitis in Indian children.

Background & objectives: Haemophilus influenzae type b (Hib) is one of the leading bacterial causes of invasive disease in populations without access to Hib conjugate vaccines (Hib-CV). India has recently decided to introduce Hib-CV into the routine immunization programme in selected States. Longitudinal data quantifying the burden of bacterial meningitis and the proportion of disease caused by various bacteria are needed to track the impact of Hib-CV once introduced. A hospital-based sentinel surveillance network was established at four places in the country and this study reports the results of this ongoing surveillance. Methods: Children aged 1 to 23 months with suspected bacterial meningitis were enrolled in Chennai, Lucknow, New Delhi, and Vellore between July 2008 and June 2010. All cerebrospinal fluid (CSF) samples were tested using cytological, biochemical, and culture methods. Samples with abnormal CSF (≥10 WBC per μl) were tested by latex agglutination test for common paediatric bacterial meningitis pathogens. Results: A total of 708 patients with abnormal CSF were identified, 89 of whom had a bacterial pathogen confirmed. Hib accounted for the majority of bacteriologically confirmed cases, 62 (70%), while Streptococcus pneumoniae and group B Streptococcus were identified in 12 (13%) and seven (8%) cases, respectively. The other eight cases were a mix of other bacteria. The proportion of abnormal CSF and probable bacterial meningitis that was caused by Hib was 74 and 58 per cent lower at Christian Medical College (CMC), Vellore, which had a 41 per cent coverage of Hib-CV among all suspected meningitis cases, compared to the combined average proportion at the other three centres where a coverage between 1 and 8 per cent was seen (P<0.001 and P= 0.05, respectively). Interpretation & conclusions: Hib was found to be the predominant cause of bacterial meningitis in young children in diverse geographic locations in India. Possible indications of herd immunity was seen at CMC compared to sites with low immunization coverage with Hib-CV. As Hib is the most common pathogen in bacterial meningitis, Hib-CV would have a large impact on bacterial meningitis in Indian children.

Increased expression of ADAM33 protein in asthmatic patients as compared to non-asthmatic controls.

Background & objectives: ADAM33 is a member of a family of genes that encode membrane-anchored proteins with a disintegrin and a metalloprotease domain, primarily expressed in lung fibroblasts and bronchial smooth muscle cells. ADAM33 has been identified as a risk factor for asthma and is known as a gene associated with airway remodelling. The present study was conducted with the aims to investigate the expression of ADAM33 protein in patients of asthma and non-asthmatic controls, and to assess if the expression of ADAM33 protein relates with severity of asthma. Methods: A total of 35 subjects, including 27 patients with asthma and eight non-asthmatic controls were included using Global Initiative for Asthma guidelines 2005. Bronchial biopsy tissues were collected and paraffin sections were made to store all study samples. Immunohistochemistry was performed using standardized protocol. Results: An increase in expression of ADAM33 protein was observed in the epithelium, smooth muscle and mesenchymal cells of asthma cases when compared to controls but there was no relationship with severity of asthma. Interpretation & conclusions: A higher expression of ADAM 33 protein was seen in asthma patients compared to controls. Large prospective studies need to be done with adequate study design to confirm these preliminary finding.

Residential Environmental Tobacco Smoke Exposure During Pregnancy and Low Birth Weight of Neonates: Case Control Study in a Public Hospital in Lucknow, India.

Objective: To determine whether residential environmental tobacco smoke (ETS) exposure during pregnancy is associated with low birth weight (LBW) neonates and establish a dose response relationship. Design: Case control study. Setting: Tertiary care hospital. Methodology: Mothers giving birth to LBW neonate (<2.5 kg) were cases and those whose neonates weighed ≥2.5 kg at birth were controls. Excluded were women smokers and tobacco chewers, high parity (>3), multiple pregnancy and still births. Included were 100 cases and 200 controls, aged 20 to 30 years. Information was collected on ETS exposure and other risk factors of LBW within 24 hours of delivery. Clinical information like maternal haemoglobin levels, birth weight and gestational age of the neonate was extracted from hospital records. R E S E A R C H P A P E R Results: On univariate analysis, preterm pregnancy, low socioeconomic status, previous LBW neonate, no utilization of antenatal care (ANC), severe anemia and ETS exposure were statistically significantly associated with LBW neonate and controlling for these in logistic regression analysis, adjusted Odds ratio for ETS exposure association with LBW neonate was 3.16 (95% CI=1.88-5.28). A dose response relationship was also found which was statistically significant (10-20 cigarettes smoked/day: OR = 4.06, 95% CI=1.78-9.26 and >20 cigarettes smoked/day, OR = 17.62, 95% CI= 3.76-82.43). Conclusion: Exposure to ETS during pregnancy is associated with LBW of neonates. Hence, there is an urgent need to increase awareness about health hazards of ETS during pregnancy and bring about behavioural changes accordingly as a one of the strategies to reduce LBW deliveries in India.

Association of CFTR gene mutation with bronchial asthma.

Mutation on both the copies of cystic fibrosis transmembrane conductance regulator (CFTR) gene results in cystic fibrosis (CF), which is a recessively transmitted genetic disorder. It is hypothesized that individuals heterozygous for CFTR gene mutation may develop obstructive pulmonary diseases like asthma. There is great heterogeneity in the phenotypic presentation and severity of CF lung disease. This could be due to genetic or environmental factors. Several modifier genes have been identified which may directly or indirectly interact with CFTR pathway and affect the severity of disease. This review article discusses the information related to the association of CFTR gene mutation with asthma. Association between CFTR gene mutation and asthma is still unclear. Report ranges from studies showing positive or protective association to those showing no association. Therefore, studies with sufficiently large sample size and detailed phenotype are required to define the potential contribution of CFTR in the pathogenesis of asthma.

Intravenous device associated blood stream staphylococcal infection in paediatric patients.

Background & objectives: Intravenous device (IVD) associated nosocomial blood stream infections due to staphylococci are major cause of morbidity and mortality. The present study was carried out to assess the frequency of staphylococcal IVD associated infections in a paediatric ward of a tertiary case hospital. Prevalence of resistance to commonly used antimicrobials in hospital acquired staphylococcal isolates was also tested. Methods: Children admitted in paediatric wards with IVD for more than 48 h were enrolled. Blood, IVD tip at the time of removal, skin swab at the site of insertion of IVD and nasal swab were collected and cultured by standard protocol. All staphylococcal isolates from any source were analyzed for antimicrobial susceptibility by disk diffusion method. Genotyping matching of those staphylococcal isolates was done which were isolated from different sites of the same patient, but were phonotypically similar. Genotype of blood isolate was compared with genotype of isolate from nose/IVD/skin. Results: Staphylococcus aureus was the most frequent blood isolate (8.7%) followed by Candida (2.9%), coagulase negative staphylococci (CoNS 2.6%), Pseudomonas spp. (0.4%), Klebsiella spp. (0.3%) and Escherichia coli (0.1%). Isolation of microorganisms from blood was significantly higher in patients whose skin, IVD and nose were colonized by same microorganism (P<0.001). None of the staphylococcal isolate was found to be resistant to glycopeptides (vancomycin and teicoplanin). High penicillin and oxacillin resistance was present in both S. aureus (penicillin resistance; 76.8%, oxacillin resistance; 66.7%) and CoNS (penicillin resistance; 73.3%, oxacillin resistance; 60.0%). Among CoNS biotypes, S. haemolyticus was commonest blood isolate while S. epidermidis was commonest isolate from Skin/nose. Only 33.3 per cent of S. aureus blood stream infections and most of S. epidermidis and S. haemolyticus blood infections were IVD associated. Interpretation & conclusions: Staphylococci were the major causative agent of nosocomial blood stream infections. All episodes of septicaemia due to S. epidermidis and S. haemolyticus were IVD associated while only 1/3 of S. aureus septicaemia was IVD associated.

Pharmacogenomics of pediatric asthma.

CONTEXT: Asthma is a complex disease with multiple genetic and environmental factors contributing to it. A component of this complexity is a highly variable response to pharmacological therapy. Pharmacogenomics is the study of the role of genetic determinants in the variable response to therapy. A number of examples of possible pharmacogenomic approaches that may prove of value in the management of asthma are discussed below. EVIDENCE ACQUISITION: A search of PubMed, Google scholar, E-Medicine, BMJ and Mbase was done using the key words “pharmacogenomics of asthma”, “pharmacogenomics of β-agonist, glucocorticoids, leukotriene modifiers, theophylline, muscarinic antagonists in asthma”. RESULTS: Presently, there are limited examples of gene polymorphism that can influence response to asthma therapy. Polymorphisms that alter response to asthma therapy include Arg16Gly, Gln27Glu, Thr164Ile for β-agonist receptor, polymorphism of glucocorticoid receptor gene, CRHR1 variants and polymorphism of LTC4S, ALOX5. Polymorphic variants of muscarinic receptors, PDE4 and CYP450 gene variants. CONCLUSION: It was concluded that genetic variation can improve the response to asthma therapy. However, no gene polymorphism has been associated with consistent results in different populations. Therefore, asthma pharmacogenomic studies in different populations with a large number of subjects are required to make possible tailoring the asthma therapy according to the genetic characteristic of individual patient.

Validation of WHO QOL-BREF instrument in indian adolescents.

Objective. To test the psychometric properties of World Health Organization Quality of Life (WHO QOL-BREF) instrument in Indian adolescents. Methods. Of 1900 schools in Lucknow city, 20 schools were invited to participate. To make WHO QOL-BREF instrument culturally appropriate for Indian adolescents, a minor modification was done by replacing one item in Social domain “Are you satisfied with your sex life?” with “Are you satisfied with the respect you receive from others?”. The revised WHO QOL-BREF was administered to subjects in school after obtaining written parental consent. Results. From August 2007 – January 2008, 525 adolescents were recruited (mean age 14.04±2.09 yr; 52.38 % males). Adolescents reported highest HRQoL in social relations and lowest in environment domain. The instrument showed good internal consistency (Cronbach’s a=0.87; p-value<0.01) as well as good content, construct and predictive validity (pvalues< 0.05). Psychological domain had best predictive validity, whereas, social relations domain had best content validity. Conclusion. The study provides evidence that revised WHO QOL-BREF is a reliable and valid instrument and can be used in Indian adolescents.

IMCI approach in tertiary hospitals, India.

Objective. This study was conducted to compare physicians’ diagnosis with Integrated Management of Childhood Illness (IMCI) algorithm generated diagnosis in hospitalized children aged 2 – 59 months. Methods. Recruited were patients aged 2-59 months admitted with one or more IMCI danger signs. IMCI and physician's diagnosis were noted and compared. Results. In 222 included subjects, mean duration of illness was 9.4 (SD: 16.5) days. Among those with cough or difficult breathing, 44 (19.8%) and 66 (29.7%) were diagnosed as either severe pneumonia or mild to moderate pneumonia by physicians and IMCI algorithm, respectively (p= 0.015). Among 146 presenting as fever, 140 (95.9%) were diagnosed as very severe febrile disease by the IMCI algorithm, whereas physicians diagnosed these as either malaria in 10/146 (6.7%), pyogenic meningitis in 47/146 (32.2%), sepsis in 31/146 (21.3%), tuberculous meningitis in 17/146 (11.6%), encephalitis in 5/146 (3.4%), measles in 3/146 (2.1%) or others in 24/146 (16.4%). Conclusion. As there was a low concordance between physician and IMCI algorithmic diagnosis of pneumonia (Kappa value= 0.74, 95% CI: (0.64 – 0.84)) and since very severe febrile disease is not a diagnosis made by the physicians, the IMCI algorithms have to be refined for appropriate management of these conditions.