Katherine Eastham

Impact of the 7-valent pneumococcal conjugate vaccine on the incidence of childhood pneumonia

SUMMARY In September 2006, the 7-valent pneumococcal conjugate vaccine (PCV7) was added to the UK immunization programme. We aimed to evaluate the impact of PCV7 on the incidence of all-cause community-acquired pneumonia (CAP) in children. A prospective survey was undertaken in 2008–2009 at 11 hospitals in North East England of children aged 0–16 years with radiologically confirmed pneumonia. Data were compared to those from a similar survey undertaken in the same hospitals in 2001–2002. A total of 542 children were enrolled, of which 74% were aged <5 years. PCV7 uptake was 90·7%. The incidence of pneumonia was 11·8/10 000 [95% confidence interval (CI) 10·9–12·9], and the hospitalization rate was 9·9/10 000 (95% CI 9·0–10·9). Compared to 2001, there was a 19% (95% CI 8–29) reduction in the rate of CAP in those aged <5 years, and in those <2 years a 33·1% (95% CI 20–45) reduction in the incidence of CAP and 38·1% (95% CI 24–50) reduction in hospitalization rates. However, for those unvaccinated aged ⩾5 years, there was no difference in the incidence of CAP and hospitalization rate between both surveys. Since 2001, the overall reduction in incidence was 17·7% (95% CI 8–26) and for hospitalization 18·5% (95% CI 8–28). For the <5 years age group there was a lower incidence of CAP in PCV7-vaccinated children (25·2/10 000, 95% CI 22·6–28·2) than in those that were not vaccinated (37·4/10 000, 95% CI 29·2–47·1). In conclusion, PCV7 has reduced both incidence and rate of hospitalization of pneumonia in children, particularly in the <2 years age group.

Heart and heart-lung transplantation in Down's syndrome. The lack of supportive evidence means each case must be carefully assessed.

Congenital heart disease is common in Downs syndrome, occurring in about 40% of individuals.1 Twenty years ago cardiac surgery was often not attempted in children with Downs syndrome because of operative mortality of up to 60% and a short life expectancy.2 With improvements in paediatric cardiac surgery and changes in attitude towards children with Downs syndrome such children now undergo corrective cardiac surgery. Some will inevitably develop complications and may benefit from heart transplant. There is also a large group of young adults with Downs syndrome who did not have heart surgery when young and who have uncorrected heart lesions that are now inoperable because of irreversible pulmonary vascular disease. They too are potential candidates for heart-lung transplantation. There is no published literature on heart or heart-lung transplantation in Downs syndrome, which makes it hard to predict the outcome in these patients. Heart transplantation is now a widely accepted treatment, and medium term survival has steadily improved.3 The results of heart-lung transplantation are not as good but have …

Aetiology of paediatric pneumonia after the introduction of pneumococcal conjugate vaccine

We describe the aetiology of community-acquired pneumonia in children before and after the introduction of the pneumococcal conjugate vaccination (PCV) programme in 2006. Prospective studies were conducted in 2001–2002 (pre-vaccine) and 2009–2011 (post-vaccine) of children aged 0–16 years with radiologically confirmed pneumonia seen in hospital. Investigations included culture, serology, immunofluorescence antibody and urine antigen testing, with an increased use of PCR assays and expanded panels of pathogens in the post-vaccine study. 241 and 160 children were enrolled in the pre- and post-vaccine studies, respectively (73% aged <5 years). Identification of a causative pathogen was higher post-vaccination (61%) than pre-vaccination (48.5%) (p=0.019). Rates of bacterial infections were not different between post- and pre-vaccine studies (17.5% versus 24%, p=0.258). Viral (31%) and mixed (12.5%) infections were found more often post-vaccination (19.5%, p=0.021) than pre-vaccination (5%, p=0.015). Rates of identified pneumococcal infections were comparable between pre- and post-vaccine studies (14.7% versus 17.4%, p=0.557). Diagnosis of pneumococcal infection post-vaccination improved when PCR was used compared to culture (21.6% versus 6%, p=0.0004). Serotypes included in PCV13 but not PCV7 were identified in 75% (18 out of 24) post-vaccination. Infection with nonvaccine pneumococcal serotypes continues to be a significant cause of pneumonia in children in the UK. Aetiology of community-acquired pneumonia in children following a pneumococcal conjugate vaccination programme http://ow.ly/p9Wub

A follow-up study of children hospitalised with community acquired pneumonia

Objective: To investigate the outcome for children hospitalised with radiologically confirmed community-acquired pneumonia (CAP) Design: Controlled follow-up study. Setting: Community based in Newcastle upon Tyne, North Tyneside and Northumberland schools. Patients: 103 cases of radiologically confirmed CAP a median of 5.6 years (range 4.4–7.4) after admission to Newcastle General Hospital, matched for sex and school class to a mean of two controls (n = 248). Interventions: A respiratory questionnaire, clinical examination and spirometry measurements. Main outcome measures: Multiple regression was used to describe associations between explanatory variables, including CAP, and outcome variables: forced expiratory volume in 1 s percent predicted (FEV1 %), forced vital capacity percent predicted (FVC %), persistent cough, doctor diagnosis of asthma and abnormal chest shape. Results: Cases were 2.9 times more likely (95% CI 1.45 to 5.71, p = 0.020) than controls to have persistent cough and 5.5 times more likely to have an abnormal chest shape (95% CI 1.65 to 18.28, p = 0.005). Cases of an atopic parent had a 7.0% deficit in FEV1 % predicted (95% CI −10.5 to −3.2, p<0.001) and a 4.4% deficit in FVC % predicted (95% CI −8.0 to −0.78, p = 0.017), but were not at increased risk of subsequent asthma. Cases of a non-atopic parent were at increased risk of subsequent asthma (OR 4.8, 95% CI 1.43 to 16.34, p = 0.011) but not of deficit in lung function. Conclusions: CAP requiring admission to hospital is associated with deficits in lung function and persistent respiratory symptoms. This has implications for follow-up for which recommendations are currently lacking. Parental atopy may be a determinant of outcome.

Accuracy of the Interpretation of Chest Radiographs for the Diagnosis of Paediatric Pneumonia

Introduction World Health Organization (WHO) radiological classification remains an important entry criterion in epidemiological studies of pneumonia in children. We report inter-observer variability in the interpretation of 169 chest radiographs in children suspected of having pneumonia. Methods An 18-month prospective aetiological study of pneumonia was undertaken in Northern England. Chest radiographs were performed on eligible children aged ≤16 years with clinical features of pneumonia. The initial radiology report was compared with a subsequent assessment by a consultant cardiothoracic radiologist. Chest radiographic changes were categorised according to the WHO classification. Results There was significant disagreement (22%) between the first and second reports (kappa = 0.70, P<0.001), notably in those aged <5 years (26%, kappa = 0.66, P<0.001). The most frequent sources of disagreement were the reporting of patchy and perihilar changes. Conclusion This substantial inter-observer variability highlights the need for experts from different countries to create a consensus to review the radiological definition of pneumonia in children.

Heart and heart-lung transplantation in Down's syndrome

Congenital heart disease is common in Downs syndrome, occurring in about 40% of individuals.1 Twenty years ago cardiac surgery was often not attempted in children with Downs syndrome because of operative mortality of up to 60% and a short life expectancy.2 With improvements in paediatric cardiac surgery and changes in attitude towards children with Downs syndrome such children now undergo corrective cardiac surgery. Some will inevitably develop complications and may benefit from heart transplant. There is also a large group of young adults with Downs syndrome who did not have heart surgery when young and who have uncorrected heart lesions that are now inoperable because of irreversible pulmonary vascular disease. They too are potential candidates for heart-lung transplantation. There is no published literature on heart or heart-lung transplantation in Downs syndrome, which makes it hard to predict the outcome in these patients. Heart transplantation is now a widely accepted treatment, and medium term survival has steadily improved.3 The results of heart-lung transplantation are not as good but have …

Community acquired pneumonia in children

Correspondence to: I J Haq iram.haq@newcastle.ac.uk #### What you need to know In 2015, community acquired pneumonia (CAP) accounted for 15% of deaths in children under 5 years old globally and 922 000 deaths globally in children of all ages.1 It is defined as a clinical diagnosis of pneumonia caused by a community acquired infection in a previously healthy child.2 Clinical assessment can be challenging; symptoms vary with age and can be non-specific in young children, and aetiology is often unknown at presentation. This article will provide an update on CAP management in otherwise healthy children outside the neonatal period and summarises recommendations from the British Thoracic Society guidelines for UK practice.2 Similar international guidelines, including the World Health Organisation and Infectious Diseases Society of America guidelines, have some treatment variations, probably dependent on drug availability, cost, and antibiotic resistance patterns.34 Around 14.4 per 10 000 children aged over 5 years and 33.8 per 10 000 under 5 years are diagnosed with CAP annually in European hospitals.56 CAP is more common in the developing world, estimated at 0.28 episodes per child per year and accounting for 95% of all cases.7 Incidence data varies and may be explained by variation in diagnostic criteria. A bias exists towards hospital based studies, which potentially underestimates overall incidence. Children aged …

Changing clinical practice: management of paediatric community-acquired pneumonia.

Rationale and aim To compare clinical features and management of paediatric community-acquired pneumonia (PCAP) following the publication of UK pneumonia guidelines in 2002 with data from a similar survey at the same hospitals in 2001–2002 (pre-guidelines). Methods A prospective survey of 11 hospitals in Northern England was undertaken during 2008–2009. Clinical and laboratory data were recorded on children aged ≤16 years who presented with clinical and radiological features of pneumonia. Results 542 children were included. There was a reduction in all investigations performed (P < 0.001) except C-reactive protein (P = 0.448) between surveys. These included full blood count (76% to 61%); blood culture (70% to 53%) and testing of respiratory secretions for viruses (24% to 12%) and bacteria (18% to 8%). Compared to pre-guidelines, there was a reduction in the use of intravenous antibiotics as a proportion of the total prescribed from 47% to 36% (P < 0.001) and a change in the route of antibiotic administration with increasing preference for oral alone (16% pre-compared to 50% post-guidelines, P < 0.001). Conclusion Apart from the acute phase reactants that should not be measured routinely, these changes are in line with the guideline recommendations. Improvements in antibiotic use are possible and have implications for future antimicrobial stewardship programmes. Further work using cost-effectiveness analysis may also demonstrate a financial benefit to health services from adoption of guidelines.Rationale and aim To compare clinical features and management of paediatric community-acquired pneumonia (PCAP) following the publication of UK pneumonia guidelines in 2002 with data from a similar survey at the same hospitals in 2001–2002 (pre-guidelines). Methods A prospective survey of 11 hospitals in Northern England was undertaken during 2008–2009. Clinical and laboratory data were recorded on children aged ≤16 years who presented with clinical and radiological features of pneumonia. Results 542 children were included. There was a reduction in all investigations performed (P < 0.001) except C-reactive protein (P = 0.448) between surveys. These included full blood count (76% to 61%); blood culture (70% to 53%) and testing of respiratory secretions for viruses (24% to 12%) and bacteria (18% to 8%). Compared to pre-guidelines, there was a reduction in the use of intravenous antibiotics as a proportion of the total prescribed from 47% to 36% (P < 0.001) and a change in the route of antibiotic administration with increasing preference for oral alone (16% pre-compared to 50% post-guidelines, P < 0.001). Conclusion Apart from the acute phase reactants that should not be measured routinely, these changes are in line with the guideline recommendations. Improvements in antibiotic use are possible and have implications for future antimicrobial stewardship programmes. Further work using cost-effectiveness analysis may also demonstrate a financial benefit to health services from adoption of guidelines.

Pneumococcal diagnosis and serotypes in childhood community-acquired pneumonia☆ , ☆☆

The 7-valent pneumococcal conjugate vaccine (PCV7) was introduced routinely in the UK from September 2006 and replaced by PCV13 in 2010. In a prospective study from 2009 to 2011 of 160 children aged ≤16 years with radiologically confirmed pneumonia, likely pneumococcal infections were identified in 26%. Detection of pneumococci was improved with polymerase chain reaction compared to culture (21.6% versus 6% of children tested, P = 0.0004). Where serotyping was possible, all (n = 23) were non-PCV7 but PCV13 serotypes; 1 (43.5%), 3 (21.7%), 7A/F, and 19A (17.4% each).

Validity of using Hospital Episode Statistics data on monitoring disease trends

We read with interest the article by Koshy et al .1 The findings are important in documenting changes in admission rates of childhood pneumonia and empyema since the introduction of heptavalent pneumococcal conjugate vaccine (PCV7). We are concerned that undue emphasis has been placed on Hospital Episode Statistics (HES) data to define the aetiology of childhood pneumonia, particularly ‘bacterial pneumonia’.2 Given the magnitude of the case numbers reported, it would appear that the analyses are based on all pneumonia …