Kerry-Ann O'Grady

Lower Respiratory Tract Infections

Acute lower respiratory infections (ALRI) are the major cause of morbidity and mortality in young children worldwide. ALRIs are important indicators of the health disparities that persist between Indigenous and non-Indigenous children in developed countries. Bronchiolitis and pneumonia account for the majority of the ALRI burden. The epidemiology, diagnosis, and management of these diseases in Indigenous children are discussed. In comparison with non-Indigenous children in developing countries they have higher rates of disease, more complications, and their management is influenced by several unique factors including the epidemiology of disease and, in some remote regions, constraints on hospital referral and access to highly trained staff. The prevention of repeat infections and the early detection and management of chronic lung disease is critical to the long-term respiratory and overall health of these children.

Increased Risk of Hospitalization for Acute Lower Respiratory Tract Infection among Australian Indigenous Infants 5–23 Months of Age Following Pneumococcal Vaccination: A Cohort Study

BACKGROUND Australian Indigenous children are the only population worldwide to receive the 7-valent pneumococcal conjugate vaccine (7vPCV) at 2, 4, and 6 months of age and the 23-valent pneumococcal polysaccharide vaccine (23vPPV) at 18 months of age. We evaluated this programs effectiveness in reducing the risk of hospitalization for acute lower respiratory tract infection (ALRI) in Northern Territory (NT) Indigenous children aged 5-23 months. METHODS We conducted a retrospective cohort study involving all NT Indigenous children born from 1 April 2000 through 31 October 2004. Person-time at-risk after 0, 1, 2, and 3 doses of 7vPCV and after 0 and 1 dose of 23vPPV and the number of ALRI following each dose were used to calculate dose-specific rates of ALRI for children 5-23 months of age. Rates were compared using Cox proportional hazards models, with the number of doses of each vaccine serving as time-dependent covariates. RESULTS There were 5482 children and 8315 child-years at risk, with 2174 episodes of ALRI requiring hospitalization (overall incidence, 261 episodes per 1000 child-years at risk). Elevated risk of ALRI requiring hospitalization was observed after each dose of the 7vPCV vaccine, compared with that for children who received no doses, and an even greater elevation in risk was observed after each dose of the 23vPPV (adjusted hazard ratio [HR] vs no dose, 1.39; 95% confidence interval [CI], 1.12-1.71; P=.002). Risk was highest among children vaccinated with the 23vPPV who had received <3 doses of the 7vPCV (adjusted HR, 1.81; 95% CI, 1.32-2.48). CONCLUSIONS Our results suggest an increased risk of ALRI requiring hospitalization after pneumococcal vaccination, particularly after receipt of the 23vPPV booster. The use of the 23vPPV booster should be reevaluated.

Respiratory Illness During Winter: A Cohort Study of Urban Children from Temperate Australia

Objective:  To examine the epidemiology and burden of respiratory illness during winter in urban children from temperate Australia.

Immunisation coverage in Australian Indigenous children: Time to move the goal posts

Childhood immunisation coverage reported at 12 to <15 months and 2 years of age, may mask deficiencies in the timeliness of vaccines designed to protect against diseases in infancy. This study aimed to evaluate immunisation timeliness in Indigenous infants in the Northern Territory, Australia. Coverage was analysed at the date children turned 7, 13 and 18 months of age. By 7 months of age, 45.2% of children had completed the recommended schedule, increasing to 49.5% and 81.2% at 13 and 18 months of age, respectively. Immunisation performance benchmarks must focus on improving the timeliness in these children in the first year of life.

Successful application of a simple specimen transport method for the conduct of respiratory virus surveillance in remote Indigenous communities in Australia

Objective  Surveillance programs and research for acute respiratory infections in remote Aboriginal communities are complicated by difficulties in the storage and transport of frozen samples to urban laboratories for testing. This study assessed the sensitivity of a simple method for transporting respiratory samples from a remote setting for viral PCR compared with frozen specimens.

FluMum : a prospective cohort study of mother-infant pairs assessing the effectiveness of maternal influenza vaccination in prevention of influenza in early infancy

Introduction Influenza vaccination in pregnancy is recommended for all women in Australia, particularly those who will be in their second or third trimester during the influenza season. However, there has been no systematic monitoring of influenza vaccine uptake among pregnant women in Australia. Evidence is emerging of benefit to the infant with respect to preventing influenza infection in the first 6 months of life. The FluMum study aims to systematically monitor influenza vaccine uptake during pregnancy in Australia and determine the effectiveness of maternal vaccination in preventing laboratory-confirmed influenza in their offspring up to 6 months of age. Methods and analysis A prospective cohort study of 10 106 mother–infant pairs recruited between 38 weeks gestation and 55 days postdelivery in six Australian capital cities. Detailed maternal and infant information is collected at enrolment, including influenza illness and vaccination history with a follow-up data collection time point at infant age 6 months. The primary outcome is laboratory-confirmed influenza in the infant. Case ascertainment occurs through searches of Australian notifiable diseases data sets once the infant turns 6 months of age (with parental consent). The primary analysis involves calculating vaccine effectiveness against laboratory-confirmed influenza by comparing the incidence of influenza in infants of vaccinated mothers to the incidence in infants of unvaccinated mothers. Secondary analyses include annual and pooled estimates of the proportion of mothers vaccinated during pregnancy, the effectiveness of maternal vaccination in preventing hospitalisation for acute respiratory illness and modelling to assess the determinants of vaccination. Ethics and dissemination The study was approved by all institutional Human Research Ethics Committees responsible for participating sites. Study findings will be published in peer review journals and presented at national and international conferences. Trial registration number The study is registered with the Australia and New Zealand Clinical Trials Registry (ANZCTR) number: 12612000175875.

Identification of radiological alveolar pneumonia in children with high rates of hospitalized respiratory infections: Comparison of WHO-defined and pediatric pulmonologist diagnosis in the clinical context†

A reliable standardized diagnosis of pneumonia in children has long been difficult to achieve. Clinical and radiological criteria have been developed by the World Health Organization (WHO), however, their generalizability to different populations is uncertain. We evaluated WHO defined chest radiograph (CXRs) confirmed alveolar pneumonia in the clinical context in Central Australian Aboriginal children, a high risk population, hospitalized with acute lower respiratory illness (ALRI).

Chronic cough postacute respiratory illness in children: a cohort study.

Objective Data on the aetiology of persistent cough at the transitional stage from subacute to chronic cough (>4 weeks duration) are scarce. We aimed to (1) identify the prevalence of chronic cough following acute respiratory illness (ARI) and (2) determine the diagnostic outcomes of children with chronic cough. Design Prospective cohort study. Setting A paediatric emergency department (ED) in Brisbane, Australia. Patients Children aged <15 years presenting with an ARI with cough. Interventions Children were followed weekly for 28 days;those with a persistent cough at day 28 were reviewed by a paediatric pulmonologist. Main outcome measures Cough persistence at day 28 and pulmonologist diagnosis. Results 2586 children were screened and 776 (30%) were ineligible; 839 children (median age=2.3 years, range=0.5 months to 14.7 years, 60% male) were enrolled over 2 years. Most children (n=627, 74.8%) had cough duration of <7 days at enrolment. At day 28, 171/839 (20.4%, 95% CI 17.7 to 23.1) children had persistent cough irrespective of cough duration at enrolment. The cough was wet in 59/171 (34.5%), dry in 45/171 (26.4%) and variable in 28/171 (16.1%). Of these 117 children , 117 (68.4%) were reviewed by a paediatric pulmonologist. A new and serious chronic lung disease was diagnosed in 36/117 (30.8%) children; 55/117 (47.0%) were diagnosed with protracted bacterial bronchitis. Conclusions When chronic cough develops post-ARI, clinical review is warranted, particularly if parents report a history of prolonged or recurrent cough. Parents of children presenting acutely to ED with cough should be counselled about the development of chronic cough, as an underlying respiratory condition is not uncommon.

Vaccines for children and adults with chronic lung disease: efficacy against acute exacerbations

Acute exacerbations of chronic lung disease are usually associated with viral and bacterial pathogens. They contribute to declining lung function, poor quality of life and exert an excess burden on individuals, families, communities and the healthcare sector. Hence, preventing exacerbations is important in clinical management. Several vaccines providing protection against respiratory pathogens (Streptococcus pneumoniae, Bordetella pertussis and influenza) that can trigger exacerbations are available, but evidence to support their effectiveness in preventing exacerbations of chronic lung disease is limited. Candidate vaccines in pre-clinical or clinical development phases include those targeting Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Pseudomonas aeruginosa, respiratory syncytial virus and human rhinoviruses. However, it is likely to be several years before vaccines against these pathogens are available for children and adults with chronic lung diseases. For vaccination to play an important role in managing chronic lung disease efforts need to be directed at understanding how various pathogens cause exacerbations and alter long-term lung function.

Lung health care for Aboriginal and Torres Strait Islander Queenslanders : breathing easy is not so easy

OBJECTIVES In Aboriginal and Torres Strait Islander peoples in Queensland, to (a) determine the disease burden of common chronic lung diseases and (b) identify areas of need with respect to lung health services. METHODS Literature reviews and analyses of hospitalisation and mortality data were used to describe disease epidemiology and available programs and services. Key stakeholder interviews and an online survey of health professionals were used to evaluate lung health services across the state and to identify services, needs and gaps. RESULTS Morbidity and mortality from respiratory diseases in the Indigenous population is substantially higher than the non-Indigenous population across all age groups and regions. There are inadequate clinical services and resources to address disease prevention, detection, intervention and management in an evidence-based and culturally acceptable fashion. There is a lack of culturally appropriate educational resources and management programs, insufficient access to appropriately engaged Indigenous health professionals, a lack of multi-disciplinary specialist outreach teams, fragmented information systems and inadequate coordination of care. CONCLUSIONS Major initiatives are required at all levels of the healthcare system to adequately address service provision for Indigenous Queenslanders with lung diseases, including high quality research to investigate the causes for poor lung health, which are likely to be multifactorial.