Risk factors for incomplete vaccination in children less than 18 months of age attending the nurseries of day-care centres in Sao Paulo, Brazil

To estimate the proportion of children in day-care centres with incomplete vaccination and to identify associated risk factors, we conducted a cross-sectional study among 258 children less than 18 months of age attending public and philanthropic day-care centres in the city of Sao Paulo, Brazil. Interviews, blood collection and anthropometry were performed. Unconditional logistic regression was adjusted for incomplete vaccination risk factors. 10.9% of children had incomplete vaccination. Children who were born prematurely (OR = 4.27; p = 0.004), or were malnourished (OR = 4.99; p = 0.049), or lived in inadequate housing (OR = 2.88; p = 0.039), or whose mothers had had poor prenatal care (OR = 4.98; p = 0.040) were more likely to have incomplete vaccination. Opportunities are being missed to identify children with incomplete vaccination; strategies to enhance vaccination coverage should pay special attention to the needs of families living in inadequate housing; and health promotion actions in primary health facilities and day-care centres should be performed as concomitant activities.     

Measles antibodies and response to vaccination in children aged less than 14 months: implications for age of vaccination

Passive immunity against measles decreases during the first months of life. The objective of this study was to determine titres of measles antibodies in children aged 9-14 months and their mothers before vaccination, and the children's response to vaccination. Blood samples were collected by capillary puncture before and 28 days after vaccination. Samples were obtained between February and June 2007 during an ongoing measles outbreak. Titres of specific measles IgG antibodies were determined by enzyme-linked immunosorbent assay. Seroconversion was defined as the presence of antibodies after vaccination in subjects without antibodies before vaccination. Maternal antibodies were present in 37·7% of all 69 children included and in 45·1% of children aged 9 months. Of the 51 children in whom a second sample was obtained, 31 (60·8%) were seronegative before vaccination and 61·3% seroconverted. Interference of maternal antibodies was 30%. Advancing the first dose of measles vaccination from 15 to 12 months is a correct strategy, given the increase in the time of susceptibility of infants to measles.     

HIV感染抗病毒治疗的副作用

HIV感染通过联合应用抗逆转录药物 ,可以将病毒载量抑制至检测不到的水平并升高CD4T细胞计数。然而 ,因为药物的毒副作用 ,长期联合治疗难于坚持。所有抗逆转录药物都有短期和长期副作用。每个药物、药物种类和患者 ,其副作用小同。因此 ,了解抗逆转录药物的副作用有益于优化HIV的治疗。     

Screening of hearing in children up to 18 months of age

In the Netherlands the hearing screening of young children is carried out at the age of nine months by the Ewing or 'Compact Amsterdam paedo-audiometric screener' (CAPAS) test. These screening tests do not always lead to the necessary follow-up diagnostics, mainly because the different disciplines disagree. Recently a consensus concerning the follow-up of children with a poor test result was reached by the Youth Health Care institutions, general practitioners, paediatricians, ENT physicians and audiologic centres. Each party has its own responsibilities and commits itself to complete the diagnostics before the age of 18 months. Until new screening methods have been validated it is advised to refer all children with poor screening test results for special diagnostics, if necessary after they have been treated for otitis media with effusion. Currently the most appropriate method for final diagnosis is the measurement of oto-acoustic emissions.     

Failure of standard antimicrobial therapy in children aged 3-59 months with mild or asymptomatic HIV infection and severe pneumonia

OBJECTIVE: To determine whether children aged 3-59 months with mild or non-symptomatic human immunodeficiency virus (HIV) infection and WHO-defined severe pneumonia have a higher failure rate than do HIV-uninfected children when treated with the standard WHO treatment of parenteral penicillin or oral amoxicillin. METHODS: This study was a planned sub-analysis of a randomized trial of 3-59-month-old children presenting with WHO-defined severe pneumonia (the APPIS study). We included two sites with high HIV prevalence in Durban, South Africa and Ndola, Zambia. Primary outcome measures were clinical treatment failure at day 2 and day 14. CLINICALTRIALS.GOV IDENTIFIER: CT00227331http://www.clinicaltrialsgov/show/NCT00227331). FINDINGS: Of the 523 children enrolled, HIV status was known for 464 participants; 106 (23%) of these were infected with HIV. By day 2, 57 (12.3%) children had failed treatment and 110 (23.7%) failed by day 14. Twenty (18.9%) HIV-infected children failed by day 2 compared with 37 (10.3%) uninfected children (adjusted odds ratio (OR) 2.07; 95% confidence interval (CI): 1.07-4.00). Thirty-four (32.1%) HIV-infected children failed treatment by day 14 compared with 76 (21.2%) uninfected children (adjusted OR 1.88; 95% CI: 1.11-3.17). Analysis stratified by age showed that the greatest differential in treatment failure at day 2 and day 14 occurred in the children aged 3-5 months. CONCLUSIONS: HIV-infected children with severe pneumonia fail WHO-standard treatment with parenteral penicillin or amoxicillin at day 2 and day 14 more often than do HIV-uninfected children, especially young infants. Standard case management of acute respiratory infection (ARI) using WHO treatment guidelines is inadequate in areas of high HIV prevalence and reappraisal of empiric antimicrobial therapy is urgently needed for severe pneumonia associated with HIV-1.     

Urgent need to improve programmatic management of patients with HIV failing first-line antiretroviral therapy

Introduction:Delayed identification and response to virologic failure in case of first-line antiretroviral therapy (ART) in resource-limited settings is a threat to the health of HIV-infected patients. There is a need for the implementation of an effective, standardized response pathway in the public sector.Discussion:We evaluated published cohorts describing virologic failure on first-line ART. We focused on gaps in the detection and management of treatment failure, and posited ways to close these gaps, keeping in mind scalability and standardization. Specific shortcomings repeatedly recorded included early loss to follow-up (>20%) after recognized first-line ART virologic failure; frequent delays in confirmatory viral load testing; and excessive time between the confirmation of first-line ART failure and initiation of second-line ART, which exceeded 1 year in some cases. Strategies emphasizing patient tracing, resistance testing, drug concentration monitoring, adherence interventions, and streamlined response pathways for those failing therapy are further discussed.Conclusion:Comprehensive, evidence-based, clinical operational plans must be devised based on findings from existing research and further tested through implementation science research. Until this standard of evidence is available and implemented, high rates of losses from delays in appropriate switch to second-line ART will remain unacceptably common and a threat to the success of global HIV treatment programs.     

The clinical characteristics and genotype distribution of Chlamydia trachomatis infection in infants less than six months of age hospitalized with pneumonia

BackgroundChlamydia trachomatis is a common sexually-transmitted bacterial pathogen. As no routine screening is performed during pregnancy, neonates and infants are at high risk for C. trachomatis infection. The objective of this study was to investigate the morbidity, clinical characteristics and genotype distribution of C. trachomatis pneumonia in infants less than six months of age.MethodsClinical manifestations and laboratory results were recorded. Respiratory sputum specimens were tested using RT-PCR targeting C. trachomatis cryptic plasmid. Simultaneously, respiratory virus antigens were detected by direct immunofluorescence and bacterial pathogens were examined by culture in all sputum samples. Positive C. trachomatis samples were further genotyped using a multiplex PCR reverse line blot assay. The relationship between genotype and pneumonia severity was explored.ResultsOf 1408 infants, 101 (7.2%) were infected with C. trachomatis. Sixteen of 101 (15.8%) were assessed as severe pneumonia. These severe cases had a higher proportion of viral co-infection (37.5%) compared to mild pneumonia cases (9.4%, P < 0.05).Infants with tachypnea (OR 9.2) and wheezing (OR 3.5) were more likely to be classified as severe pneumonia (P < 0.05). Amongst 66 C. trachomatis specimens for which a genotyping result was available, seven genotypes were detected, and 39.4% of these specimens contained two or three genotypes. Overall, genotype E (48.5%) was the most frequent, followed by genotype F (42.4%), J (31.8%), D (12.1%), K (10.6%), G (4.5%) and H (3.0%). There were no significant correlations of particular genotypes with severity of disease, although there was a weak indication that more severe pneumonia might be associated with having certain mixed genotypes of C. trachomatis.ConclusionsThe prevalence of C. trachomatis in the population of young hospitalized infants with pneumonia in Shenzhen was very high. The relationship between genotype distribution and severity of pneumonia was not clear based on this study due to small sample size. Further in-depth investigation correlating genotype and disease severity based on a larger population is needed.     

Fever in children younger than three months of age. A pooled analysis

Concern that febrile infants younger than 3 months of age are at high risk of serious infection has prompted a management policy of routine hospitalization with antibiotic administration. Ten published studies of febrile infants younger than 3 months of age were reviewed, and data were statistically combined to develop estimates of the risk of bacteremia and serious infection. Factors that predicted increased risk were similarly evaluated. Mean and median risk estimates included, respectively, 3.0 and 3.4 percent for bacteremia, 1.3 and 1.0 percent for septic meningitis, and 5.0 and 7.0 percent for pneumonia. These were no higher than comparable estimates for older infants. Clinical appearance was 92 percent sensitive in predicting bacteremia in 500 infants (23 of 25 cases). Younger age, higher fever, and elevated white blood cell count were associated with increased risk of serious infection. Data from these studies do not support the belief that febrile infants younger than 3 months are uniformly at greater risk of serious infection than older infants. Judicious evaluation of younger infants could lead to more selective, cost-efficient management.     

Vision testing of young children in the age range 18 months to 4½ years

Four hundred and twenty-five normal children in the age range 18 months to 4 1/2 years have been studied to determine the percentage of children according to age who can be expected to cooperate in a letter-matching vision test using a key card; to see whether the use of plastic letters to replace the key card lowers the age at which a letter-matching test can be achieved, and to show that children in this age range can do a vision test at 20ft (6m). Acceptance of occlusion using a patch occluder was also examined. The study shows that children effectively begin to cooperate in letter-matching vision tests using a key card from 33 months of age. Replacement of the key card with plastic letters lowers the age to 30 months and thereafter there is a gain of some 25% of children up to 39 months. All children were successfully tested at 20ft (6m). The most difficult age for occlusion was in the age group around the second birthday.     

2013年中国2岁以下婴幼儿早开奶状况

目的分析中国2岁以下婴幼儿早开奶状况。方法数据来自2013年中国居民营养与健康状况监测项目中2岁以下婴幼儿调查资料。2013年采用分层整群随机抽样方法,抽取中国55个监测点的14 825名2岁以下婴幼儿,采用询问调查的方式从看护人处获得包括是否实现早开奶、未早开奶的原因、开奶时间段等信息,分析婴幼儿早开奶状况、影响因素和开奶时间构成比。结果 2013年中国2岁以下婴幼儿早开奶率为26. 4%,大城市、中小城市、普通农村和贫困农村分别为30. 1%、24. 1%、23. 2%和36. 9%。剖宫产是影响大城市(40. 7%)、中小城市(51. 5%)和普通农村(33. 8%)婴幼儿早开奶的最主要因素,贫困农村以缺乏早开奶知识为主(44. 6%)。中国婴幼儿1～23小时开奶率和24小时及以上开奶率分别占31. 0%和35. 3%,其中大城市分别为31. 2%和33. 4%,中小城市分别为35. 4%和34. 4%,普通农村分别为26. 9%和42. 3%,贫困农村分别为29. 5%和23. 5%。结论中国2岁以下婴幼儿早开奶率均处于较低水平,剖宫产和缺乏早开奶知识分别为城市和农村地区的主要影响因素,部分婴幼儿接触母亲乳房的时间被严重推迟。     

Early impact of rotavirus vaccination in children less than five years of age in Mozambique

BackgroundMozambique introduced rotavirus vaccine (Rotarix, GSK Biologicals) in the National Immunization Program in September 2015 with the objective of reducing the burden of total diarrheal disease and specifically severe rotavirus disease. This study aimed to evaluate the early impact of rotavirus vaccine in reducing all-cause diarrhea and rotavirus-specific hospitalizations.MethodsWe analysed stool specimens collected from children under five years old, between January 2014 and June 2017 within the National Surveillance for Acute Diarrhea. We compared annual changes in rotavirus positivity, median age of children hospitalized for rotavirus and the number of all-cause for diarrheal hospitalizations. Rotavirus detection was performed using enzyme immunoassay.ResultsDuring this period, 1296 samples were collected and analyzed. Rotavirus positivity before vaccine introduction was 40.2% (39/97) in 2014 and 38.3% (225/588) in 2015, then after vaccine introduction reduced to 12.2% and 13.5% in 2016 and 2017, respectively. The median age of children hospitalized for rotavirus was 9 and 11 months in 2014 and 2015 and 10 months in 2016 and 2017. Rotavirus hospitalizations exhibited a seasonal peak prior to vaccine introduction, between June and September in 2014 and 2015, coinciding with winter period in Mozambique. After vaccine introduction, the peak was delayed until August to December in 2016 and was substantially diminished. There was a reduction in all-cause acute diarrhea hospitalizations in children aged 0–11 months after vaccine introduction.ConclusionWe observed a reduction in rotavirus positivity and in the number of all-cause diarrhea hospitalizations after vaccine introduction. The data suggest rotavirus vaccine is having a positive impact on the control of rotavirus diarrheal disease in Mozambique.     

Shigellosis remains an important problem in children less than 5 years of age in Thailand

This is a review of existing data on the burden of shigellosis in Thailand to determine trends, vulnerable groups, predominant species and serotypes, and antimicrobial resistance patterns. Diarrhoea and dysentery morbidity and mortality data from 1991 to 1999 was collected from the routine surveillance system and demographic data from the government census. International and local literature published between 1988 and 2000 was systematically reviewed. Based on the routine surveillance system, the annual incidence of bacillary dysentery decreased from 1.3 to 0.2/10,000 persons per year. The remaining burden is highest in children <5 years of age at 2.7/10,000 persons per year. In comparison, a prospective study utilizing active surveillance found an incidence in children <5 years of age that was more than 100-fold higher at 640/10,000 persons per year. Despite the decrease in morbidity and mortality based on routinely collected data, shigellosis remains an important problem in children <5 years of age in Thailand.     

Vitamin A deficiency is prevalent in children less than 5 y of age in Nigeria

Vitamin A deficiency (VAD) is a serious and widespread public health problem in developing countries. We conducted a nationwide food consumption and nutrition survey in Nigeria to help fomulate strategies to address VAD, among other deficiencies. One objectives was to assess the vitamin A status of children <5 y old. A total of 6480 households with a mother and child <5 y old were randomly sampled. Blood samples were collected by venipuncture and processed to obtain serum for measurement of retinol concentration by HPLC. Nationwide, 29.5% of children <5 y old were vitamin A deficient (serum retinol <0.70 micromol/L). The proportions of children with VAD differed among the agroecological zones; incidences were 31.3% in the dry savanna, 24.0% in the moist savanna, and 29.9% in the humid forest (P < 0.001). More children (P < 0.05) with severe deficiency (serum retinol < 0.35 micromol/L) lived in the humid forest (7.1%) than in the dry (3.1%) or moist savanna (2.4%). The distribution of VA in children <5 y old was 25.6% in the rural sector, 32.6% in the medium, and 25.9% in the urban sector (P < 0.05). In conclusion, VAD is a severe public health problem in Nigeria. Although the proportion of children with low serum vitamin A levels varies agroecologically and across sectors, it is an important public health problem in all zones and sectors.     

Association between ozone and hospitalization for acute respiratory diseases in children less than 2 years of age

To clarify the health effects of ozone exposure in young children, the authors studied the association between air pollution and hospital admissions for acute respiratory problems in children less than 2 years of age during the 15-year period from 1980 to 1994 in Toronto, Canada. The daily time series of admissions was adjusted for the influences of day of the week, season, and weather. A 35% (95% confidence interval: 19%, 52%) increase in the daily hospitalization rate for respiratory problems was associated with a 5-day moving average of the daily 1-hour maximum ozone concentration of 45 parts per billion, the May-August average value. The ozone effect persisted after adjustment for other ambient air pollutants or weather variables. Ozone was not associated with hospital admissions during the September-April period. Ambient ozone levels in the summertime should be considered a risk factor for respiratory problems in children less than 2 years of age.     

Evaluation of the localization auditory screening test in children 6-18 months of age.

The present paper is a report of a project to develop an automated auditory screening test for infants six to 18 months of age. The first year of the project was devoted to developing equipment and test procedures; the second year was concerned with testing the effectiveness of the equipment and procedures on an actual population of six to 18 month old infants. Two-hundred and fifty infants were screened auditorily as part of a county health department child development clinic. The pass/fail results of the screening test were evaluated in terms of physical and developmental examination following the screening and by means of a case review of the child's previous history. The results indicate that the procedure under investigation can be used to differentiate the normal hearing infant from the infant with possible hearing problems. It is shown by the test environment in which this study was conducted that the procedure reported can be successfully incorporated into a public health program, i.e., child development clinics or EPSDT programs.     

New CIMDER measuring tapes for screening nutritional status in children less than 5 years of age

The measurement of mid‐upper arm circumference (MUAC) using CIMDER tapes to assess the nutritional status of children aged 5 years and younger first occurred nearly 40 years ago. In this study, new CIMDER tapes were developed to assess severe and moderate malnutrition, mild malnutrition and, for the first time using the MUAC method, overweight in children aged less than 5 years, based on the World Health Organization (WHO) MUAC (2006) reference standards. The tapes were developed for boys and girls and specified for four age ranges: 3–6 months, 6.1–18 months, 18.1–36 months and 36.1–60 months. The weight, age and MUAC of 1283 children were assessed to evaluate the accuracy and concordance of the new CIMDER tapes with the WHO weight‐for‐age reference standards. The new CIMDER tapes were found to have good accuracy and concordance with the WHO weight‐for‐age reference standards across all age and sex groups. These results suggest that the new CIMDER tapes can be used in place of WHO weight‐for‐age growth charts for screening nutritional status of children less than 5 years of age, including for risk of malnutrition and overweight.     

Correlation of selenium and zinc levels to antiretroviral treatment outcomes in Thai HIV-infected children without severe HIV symptoms

Background/Objectives:Deficiencies in antioxidants contribute to immune dysregulation and viral replication. To evaluate the correlation of selenium (Se) and zinc (Zn) levels on the treatment outcomes in HIV-infected children.Subjects/Methods:HIV-infected Thai children 1-12 years old, CD4 15-24%, without severe HIV symptoms were included. Se and Zn levels were measured by graphite furnace atomic absorption spectrometry at baseline and 48 weeks. Deficiency cutoffs were Se <0.1?μmol/l and Zn <9.9?μmol/l. Serum ferritin and C-reactive protein (CRP) were measured every 24 weeks. No micronutrient supplement was prescribed.Results:In all, 141 children (38.3% male) with a median (interquartile range (IQR)) age of 7.3 (4.2-9.0) years were enrolled. Median baseline CD4% was 20%, HIV-RNA was 4.6?log(10)copies/ml. At baseline, median (IQR) Se and Zn levels were 0.9 (0.7-1.0) μmol/l and 5.9 (4.8-6.9) μmol/l, respectively. None had Se deficiency while all had Zn deficiency. Over 48 weeks, 97 initiated antiretroviral therapy (ART) and 81% achieved HIV-RNA <50 copies/ml with 11% median CD4 gain. The mean change of Se was 0.06?μmol/l (P=0.003) and Zn was 0.42?μmol/l (P=0.003), respectively. By multivariate analysis in children who received ART, predictors for greater increase of CD4% from baseline were lower baseline CD4% (P<0.01) and higher baseline Zn level (P=0.02). The predictors for greater decrease of HIV-RNA from baseline were higher baseline HIV-RNA and higher ferritin (both P<0.01). No association of CRP with the changes from baseline of CD4% or HIV-RNA was found.Conclusion:In HIV-infected Thai children without severe immune deficiency who commenced ART, no correlation between Se and ART treatment outcomes was found. Higher pre-ART Zn levels were associated with significant increases in CD4% at 48 weeks.