Comparison of clinical outcome with oral and inhaled bronchodilators in the management of wheezy children aged 1-59 months in the community: a randomised trial in Pakistan.

BACKGROUND: Wheeze is a significant problem in children. There is a gradual trend of switching from oral to inhaled bronchodilator therapy. No randomised trials have been carried out in the community to compare the clinical outcome of two modes of therapy. If outcome with oral and inhaled bronchodilators is the same in young wheezers in developing countries, it will be easier to manage them. METHODS: In a randomised multicentre trial, wheezy children aged 1-59 months with fast breathing and/or lower chest indrawing received oral or inhaled salbutamol at home after responding to up to three cycles of inhaled bronchodilators. They were re-assessed on days 3 and 5 for clinical outcome. RESULTS: From May 2001 to August 2002, 780 children were enrolled; 390 each were randomised to oral and inhaled salbutamol. On day 5, 324 (83.1%) children in the oral and 328 (84.1%) in the inhaled group were completely well. There were no differences in clinical outcome of both modes of therapy. CONCLUSIONS: The clinical outcome of children aged 1-59 months with wheeze is similar when treated with oral or inhaled salbutamol. Acute respiratory infection control programmes in developing countries should continue to use oral bronchodilators for the management of wheeze to save both time and money.

Assessment and management of children aged 1-59 months presenting with wheeze, fast breathing, and/or lower chest indrawing; results of a multicentre descriptive study in Pakistan.

BACKGROUND AND AIMS: Using current WHO guidelines, children with wheezing are being over prescribed antibiotics and bronchodilators are underutilised. To improve the WHO case management guidelines, more data is needed about the clinical outcome in children with wheezing/pneumonia overlap. METHODOLOGY: In a multicentre prospective study, children aged 1-59 months with auscultatory/audible wheeze and fast breathing and/or lower chest indrawing were screened. Response to up to three cycles of inhaled salbutamol was recorded. The responders were enrolled and sent home on inhaled bronchodilators, and followed up on days 3 and 5. RESULTS: A total of 1622 children with wheeze were screened from May 2001 to April 2002, of which 1004 (61.8%) had WHO defined non-severe and 618 (38.2%) severe pneumonia. Wheeze was audible in only 595 (36.7%) of children. Of 1004 non-severe pneumonia children, 621 (61.8%) responded to up to three cycles of bronchodilator. Of 618 severe pneumonia children, only 166 (26.8%) responded. Among responders, 93 (14.9%) in the non-severe and 63 (37.9%) children in the severe pneumonia group showed subsequent deterioration on follow ups. No family history of wheeze, temperature >100 degrees F, and lower chest indrawing were identified as predictors of subsequent deterioration. CONCLUSIONS: Two third of children with wheeze are not identified by current WHO ARI (acute respiratory infections) guidelines. Antibiotics are over prescribed and bronchodilators under utilised in children with wheeze. Children with wheeze constitute a special ARI group requiring a separate management algorithm. In countries where wheeze is common it would be worthwhile to train health workers in use of the stethoscope to identify wheeze.

Seroepidemiology of varicella-zoster in Pakistan.

The availability of safe and effective vaccines has renewed interest in the epidemiology of varicella worldwide. To date published data on the epidemiology of varicella in Pakistan is very scarce. Therefore, we conducted a study to determine the age-specific seroprevalence rate of varicella-zoster virus (VZV) antibodies in Pakistan. Between December 1997 and March 1998, 1,509 healthy volunteers aged between 1 month and 30 years were recruited from the Islamabad, Karachi, Lahore and Rawalpindi areas. Demographic information, socioeconomic status and past medical history were obtained by questionnaire. Serum samples were assayed for IgG antibodies against VZV by enzyme-linked immunosorbent assay. Overall 41.8% (600/1,435) of those tested were found to be seropositive for VZV antibodies. No difference was found in results obtained from the different cities. A higher seroprevalence was observed among women (45.2%) compared to men (39.6%). Seroprevalence rates increased with age and were 28.4% in those aged 0-5 years, 41.5% in the 6-10 year age group, 42.5% in the 11-15 year age group, 46.7% in the 16-20 year age group and 53.6% in those aged 21-30 years. Socioeconomic status was not a significant risk factor for VZV seropositivity. This is the first report of the seroepidemiology of VZV in Pakistan. The results indicate that seroprevalence of VZV increases with age in the Pakistani population studied. As in other tropical countries, there is greater susceptibility to varicella among the adolescent and young adult population. The results of this study suggest that these at-risk groups should be included in vaccination programs aimed at reducing the public health impact of varicella.

Determinants of neonatal mortality.

OBJECTIVES: To identify the common causes and contributory factors for high neonatal mortality in Pakistan and propose effective strategies to safeguard against it. METHODS: This retrospective study was carried out in Neonatal Unit (NNU) of Rawalpindi General Hospital (RGH) from January 1995 to December 1996. Relevant prenatal information obtained from referral forms, admission files or attendants was recorded on a proforma at the time of death of a newborn. This included obstetric and medical management of the mother, neonatal resuscitation and care, birth weight (wt) and gestational age. Cause of death was based on available clinical and laboratory data. RESULTS: During the study period, there were 3005 admissions and 268 deaths, resulting in 9% neonatal mortality. Eighty-eight percent of this mortality was due to early neonatal deaths. More than 50% of deaths were unavoidable due to their critical condition at admission and occurred within first 24 hours of hospitalization. Neonatal infections and birth asphyxia were two major causes of neonatal mortality (37% and 31% respectively), followed by idiopathic respiratory distress syndromes (IRDS), Meconium aspiration syndrome (MAS) and congenital malformations. Sixty-eight percent of mortality was contributed by low birth weight (LBW), 74% of them being preterm suggesting high mortality among LBW-preterm infants. Other less common contributory factors were maternal medical disease, complicated deliveries and multiple gestation. CONCLUSION: These causes and contributory factors of neonatal mortality reflect poor prenatal health services in this country. Hence there is a need for coordinated efforts to organise and regionalize MCH and prenatal health services with the help of a neonatal task force.

Antimicrobial resistance and clinical effectiveness of co-trimoxazole versus amoxycillin for pneumonia among children in Pakistan: randomised controlled trial. Pakistan Co-trimoxazole Study Group.

BACKGROUND: Co-trimoxazole is widely used in treatment of paediatric pneumonia in developing countries, but drug resistance may decrease its effectiveness. We studied the effectiveness of co-trimoxazole compared with that of amoxycillin in pneumonia therapy, and assessed the clinical impact of co-trimoxazole resistance. METHODS: We recruited 595 children, aged 2-59 months, with non-severe or severe pneumonia (WHO criteria) diagnosed in the outpatient wards of two urban Pakistan hospitals. Patients were randomly assigned on a 2:1 basis co-trimoxazole (n=398) or amoxycillin (n=197) in standard WHO doses and dosing schedules, and were monitored in study wards. The primary outcome was inpatient therapy failure (clinical criteria) or clinical evidence of pneumonia at outpatient follow-up examination. FINDINGS: There were 92 (23%) therapy failures in the co-trimoxazole group and 30 (15%) in the amoxycillin group (p=0.03)-26 (13%) versus 12 (12%) among children with non-severe pneumonia (p=0.856) and 66 (33%) versus 18 (18%) among those with severe pneumonia (p=0.009). For patients with severe pneumonia, age under 1 year (p=0.056) and positive chest radiographs (p=0.005) also predicted therapy failure. There was no significant association between antimicrobial minimum inhibitory concentration and outcome among bacteraemic children treated with co-trimoxazole. INTERPRETATION: Co-trimoxazole provided effective therapy in non-severe pneumonia. For severe, life-threatening pneumonia, however, co-trimoxazole is less likely than amoxycillin to be effective.

Differentials in health-related variables among children at a diarrhoea training unit in Pakistan.

The study assesses gender differences and other variables related to diarrhoea in 500 children less than two years of age at a diarrhoea training unit (DTU). During the study period, 78% of the children (51% males and 49% females) who were brought for care had no dehydration. More female children were malnourished than male. Exclusively bottle-fed infants were malnourished in higher proportion than those breastfed exclusively or partially. With worsening of nutritional status, severity of dehydration increased but it had no effect on the frequency of dysentery which was seen in 11 females and 10 males. Appropriate supplementary feeding was alarmingly low. Eighty-seven per cent of children 9-24 months of age had received their immunisation against measles. All children were rehydrated at the DTU and not a single case required admission. The study does not show preferential care-seeking for male children and suggests that educational efforts be focused on exclusive breastfeeding, appropriate weaning and home management of those cases with no dehydration.

Transmission of Salmonella worthington by oropharyngeal suction in hospital neonatal unit.

An outbreak of Salmonella worthington infection in a neonatal unit occurred in a pediatric ward of Holy Family Hospital, Rawalpindi, Pakistan. The index case was a prematurely born male child from whose clinical specimens S. worthington was recovered. After this finding 40 infants kept in that nursery were included in an investigation. Major symptoms were diarrhea, septicemia and jaundice. Three developed meningitis. Disease morbidity rate was 45% and mortality occurred in 16.6% of the total positive cases. The source of infection was traced to a contaminated rubber tubing of a suction apparatus which was used for oropharyngeal suction of the babies. S. worthington was recovered from the clinical specimens of all 18 babies who received suction. Multiple drug resistance of these S. worthington strains was found.