Predictors of death from severe pneumonia among children 2-59 months old hospitalized in Bohol, Philippines: implications for referral criteria at a first-level health facility.

OBJECTIVE: To determine predictors of death among children 2-59 months old admitted to hospital with severe pneumonia. METHODS: Prospective observational study from April 1994 to May 2000 to investigate serious infections in children less than 5 years old admitted to a tertiary care government hospital in a rural province in central Philippines. The quality of clinical and laboratory work was monitored. The WHO classification for severe pneumonia was used for patient enrolment. RESULTS: There were 1249 children with severe pneumonia and no CNS infection. Thirty children died. Using univariate analysis, the following factors were significantly associated with death: age 2-5 months, dense infiltrates on chest radiography and presence of definite bacterial pathogens in the blood. Stepwise logistic regression analysis revealed the following independent predictors of death: age 2-5 months, weight for age z-score less than -2 SD, dense infiltrates on chest radiography and definite pathogens isolated in the blood. When the results of chest radiographs and blood cultures were not included to mimic facilities available at first-level facilities, age 2-5 months and weight for age z-score less than -2 SD remained independent predictors of death. CONCLUSION: When resources are limited, children with lower chest wall indrawing (severe pneumonia) who are 2-5 months old or moderately to severely malnourished should be referred for immediate higher-level care.

Serious community-acquired neonatal infections in rural Southeast Asia (Bohol Island, Philippines).

OBJECTIVE: To determine the bacterial etiology, clinical presentation and risk factors for outcome of serious community-acquired infections in young infants. STUDY DESIGN: Infants younger than 60 days, admitted for severe pneumonia or suspected sepsis/meningitis were prospectively evaluated using complete blood count, blood culture, chest radiograph, cerebrospinal fluid (CSF) culture in suspected meningitis. chi2 or Fisher's exact test and stepwise logistic regression were used for analysis. RESULTS: Thirty-four of 767 enrolled infants had a positive blood or CSF culture. Gram-negative bacteria were more frequent than Gram positive: overall (P=0.004), in those below 7 days of age (P=0.002) and among home deliveries (P=0.012). Case fatality rates were higher among infants below 1 week old (OR 4.14, P<0.001), those with dense (OR 2.92, P<0.001) or diffuse radiographic infiltrates (OR 2.79, P=0.003). CONCLUSIONS: Gram-negative enteric bacteria are the predominant causes of community-acquired infections in Filipino infants below 2 months old. Age below 7 days and radiographic pneumonia predicted death.

Blood culture confirmed typhoid fever in a provincial hospital in the Philippines.

Epidemiological features of blood culture confirmed typhoid fever and antibiotic sensitivity of isolated Salmonella typhi strains were investigated in Bohol Province in Central Philippines from where no earlier information of these was avialable. Typhoid fever is endemic elsewhere in the Philippines (eg Metropolitan Manila and surroundings) where also multidrug resistant S. typhi strains have been detected. A laboratory for surveillance of invasive bacterial infections was established in a tertiary care government hospital, in Bohol, Central Philippines, in 1994. Patients with suspected typhoid fever or other serious infection were managed and blood cultures from them were taken according to clinicians' judgment. Blood cultures were processed and the isolated bacteria identified using generally accepted methods. S. typhi and other Salmonella isolates were identified using commercial antisera. Patient data were collected from hospital records. Of a total of 4,699 blood cultures done during a period of 3 3/4 years, 1,530 (32%) were requested for suspected typhoid fever. S. typhi was the most common pathogen isolated from 422 patients (8.9%), followed by S. paratyphi A from 55 patients (1%). Most patients were young adults (43%) and school age children (28%). Male:female ratio was 1.5:1. Among the 422 patients, there were 9 (2%) deaths due to typhoid fever, all with complications. All S. typhi isolates were sensitive to chloramphenicol, cotrimoxazole, and ampicillin. Our observation on blood culture confirmed typhoid fever demonstrates its importance as a major infectious disease in Bohol and gives a sound basis for treatment of typhoid patients and for further clinical and epidemiologic studies of typhoid fever and for following antibiotic sensitivity of S. typhi in Bohol and elsewhere in the Philippines.

Invasive bacterial infections of children in a rural province in the central Philippines.

The etiology of invasive bacterial infections was studied among 956 Filipino children less than five years old who fulfilled the World Health Organization criteria for severe or very severe pneumonia or had suspected meningitis or sepsis. The most common invasive infections were due to Streptococcus pneumoniae (12 [1.3%]) and Haemophilus influenzae (12 [1.3%]); including four cases of pneumococcal meningitis and 11 cases of H. influenzae meningitis. Type 1 was the most common (six of the 12 isolates) of the pneumococcal serotypes. Serotypes/groups 1, 6, 14, and 23 accounted for 91.7% of the invasive isolates. The majority of the H. influenzae strains from blood (10 out of 10) and cerebrospinal fluid (6 out of 7) were type b. Almost all of the invasive S. pneumoniae (9 out of 12) and H. influenzae (11 out of 12) infections were seen before one year of age, which stresses the need to investigate early immunization of children for H. influenzae type b and S. pneumoniae, as well as maternal immunization to maximize the potential of immunoprophylaxis.

Establishing a laboratory for surveillance of invasive bacterial infections in a tertiary care government hospital in a rural province in the Philippines.

A clinical bacteriologic laboratory was established in a tertiary care government hospital in The Philippines, where expert bacteriologic laboratories do not usually exist at this level of health care. The laboratory was jointly established by the Research Institute for Tropical Medicine (RITM) (Manila, The Philippines) and the National Public Health Institute (KTL) (Helsinki, Finland). The laboratory was planned, its personnel were trained, and its functioning was continuously supported by the RITM and KTL. The following aspects were of utmost importance in establishing the laboratory and launching its work: 1) the support of the RITM bacteriologic laboratory, with back-up and consultations from KTL; 2) creation and maintenance of personal contacts between clinicians and laboratory staff with an emphasis on clinical relevance and rapid reporting of laboratory results; 3) the consideration of the quality aspects of the work from the start; and 4) keen follow-up of the bacteriologic results and their clinical significance and use, of practical laboratory work, and of quality assurance aspects. In the first two years of its operation, the laboratory identified Streptococcus pneumoniae and Haemophilus influenzae as the most important causes of severe pneumonia, sepsis or meningitis in children less than two years of age, and Salmonella typhi as the most frequent significant isolate from the blood cultures, being found most often in school age children and young adults.

Malnutrition and acute respiratory tract infections in Filipino children.

The impact of malnutrition on morbidity and mortality associated with acute respiratory tract infection (ARI) was studied in Filipino children less than 5 years old. Malnutrition measured by weight-for-age Z-scores of less than -3 SD and less than -2 SD from the National Center for Health Statistics median reference population was associated with the following significant relative risks of morbidity: 1.24 (95% confidence interval [CI] = 1.14, 1.34) and 1.14 (95% CI = 1.08, 1.19), respectively, for ARI; and 1.9 (95% CI = 1.46, 2.39) and 1.2 (95% CI = 1.03, 1.47), respectively, for acute lower respiratory tract infection (ALRI). These risk ratios remained significant when adjusted for age, crowding, and parental smoking. Malnourished children with severe ALRI also had a mortality risk two to three times higher than that of healthy children. This risk remained significant even when adjusted for significant predictors of mortality, including clinical complications, concurrent measles, severe infections, and female gender; and for clinical factors, including extent of pneumonic infiltrates, dehydration, and hepatic enlargement. These findings underscore the importance of nutritional intervention in the control of morbidity and mortality among patients with ARI.

Patterns of acute respiratory tract infection in children: a longitudinal study in a depressed community in Metro Manila.

The incidences of acute respiratory tract infection (ARI) and acute lower respiratory infection (ALRI) were 6.1 and 0.5 per child-year, respectively, in children less than 5 years old in a depressed urban community in Manila. The peak age-specific incidence occurred in those children 6-23 months old for ARI and 6-11 months old for ALRI. Age less than 2 years, malnutrition, household crowding, and parental smoking were associated with a statistically significant, though modest, increase in ARI morbidity. The crude mortality rate was 14.3 per 1,000 children 0-4 years old, with a corresponding ARI-specific mortality rate of 8.9 per 1,000. The prevalence of viral infection was 32.8 and that of bacteremic ALRI was 6.7 per 1,000 children with moderate ALRI. Respiratory syncytial virus was the predominant viral pathogen, while Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus were the most frequently isolated bacterial pathogens. Transmission of respiratory pathogens in depressed communities, facilitated by inadequate housing, inaccessible health services, and prevalent malnutrition, will continue unless meaningful socioeconomic improvement is realized.

Child care practices of mothers: implications for intervention in acute respiratory infections.

An epidemiological study of acute respiratory infection (ARI) in an urban community showed poor utilization of available health services. This prompted us to undertake this study to identify determinants of child care practices of mothers through a focus group discussion and survey of the knowledge, attitudes and practices of mothers. The results will form the basis of appropriate health education strategy geared towards control of ARI. They showed that, generally, the mothers were unable to recognize a severe infection. Poor diagnostic ability compounded by a limited knowledge of the appropriate management of varying types or degrees of ARI resulted in inappropriate action. Consequently, there was a high rate of self-medication and a low rate of health service utilization. In addition, there was low compliance with childhood immunizations. With these limitations in the mother's knowledge and practices, an education programme utilizing an informative print material was devised to upgrade the mother's ability to recognize signs of ARI and to improve her management of the condition.