BackgroundThe highest incidence of childhood acute lower respiratory tract infection (ALRI) is in low- and middle-income countries. Few studies examined whether detection of respiratory viruses predicts ALRI outcomes in these settings.MethodsWe conducted prospective cohort and case-control studies of children 1-23 months of age in Botswana. Cases met clinical criteria for pneumonia and were recruited within six hours of presentation to a referral hospital. Controls were children without pneumonia matched to cases by primary care clinic and date of enrollment. Nasopharyngeal specimens were tested for respiratory viruses using polymerase chain reaction. We compared detection rates of specific viruses in matched case-control pairs. We examined the effect of respiratory syncytial virus (RSV) and other respiratory viruses on pneumonia outcomes.ResultsBetween April 2012 and August 2014, we enrolled 310 cases, of which 133 had matched controls. Median ages of cases and controls were 6.1 and 6.4 months, respectively. One or more viruses were detected from 75% of cases and 34% of controls. RSV and human metapneumovirus were more frequent among cases than controls, but only enterovirus/rhinovirus was detected from asymptomatic controls. Compared with non-RSV viruses, RSV was associated with an increased risk of treatment failure at 48 hours [risk ratio (RR): 1.85; 95% confidence interval (CI): 1.20, 2.84], more days of respiratory support [mean difference (MD): 1.26 days; 95% CI: 0.30, 2.22 days], and longer duration of hospitalization [MD: 1.35 days; 95% CI: 0.20, 2.50 days], but lower in-hospital mortality [RR: 0.09; 95% CI: 0.01, 0.80] in children with pneumonia.ConclusionsRespiratory viruses were detected from most children hospitalized with ALRI in Botswana, but only RSV and human metapneumovirus were more frequent than among children without ALRI. Detection of RSV from children with ALRI predicted a protracted illness course but lower mortality compared with non-RSV viruses.

HIV-EU children with pneumonia have higher rates of treatment failure and in-hospital mortality than HIV-unexposed children during the first 6 months of life. Treatment with a third-generation cephalosporins did not improve outcomes among HIV-EU children.

Background Chest radiography is increasingly used to diagnose pneumonia in low- and middle-income countries. Few studies examined whether chest radiographic findings predict outcomes of children with clinically suspected pneumonia in these settings. Methods Hospital-based, prospective cohort study of children 1-23 months of age meeting clinical criteria for pneumonia in Botswana. Chest radiographs were reviewed by two pediatric radiologists to generate a consensus interpretation using standardized World Health Organization criteria. We assessed whether final chest radiograph classification was associated with our primary outcome, treatment failure at 48 hours, and secondary outcomes. Results From April 2012 to November 2014, we enrolled 249 children with evaluable chest radiographs. Median age was 6.1 months and 58% were male. Chest radiograph classifications were primary end-point pneumonia (35%), other infiltrate/abnormality (42%), or no significant pathology (22%). The prevalence of end-point consolidation was higher in children with HIV infection (P=0.0005), while end-point pleural effusions were more frequent among children with moderate or severe malnutrition (P=0.0003). Ninety-one (37%) children failed treatment and 12 (4.8%) children died. Primary end-point pneumonia was associated with an increased risk of treatment failure at 48 hours (P=0.002), a requirement for more days of respiratory support (P=0.002), and a longer length of stay (P=0.0003) compared with no significant pathology. Primary end-point pneumonia also predicted a higher risk of treatment failure than other infiltrate/abnormality (P=0.004). Conclusions Chest radiograph provides useful prognostic information for children meeting clinical criteria for pneumonia in Botswana. These findings highlight the potential benefit of expanded global access to diagnostic radiology services.

Setting Tertiary hospital in Gaborone, Botswana. Objective To examine whether exposure to wood smoke worsens outcomes of childhood pneumonia. Design Prospective cohort study of children 1-23 months of age meeting clinical criteria for pneumonia. Household use of wood as a cooking fuel was assessed during a face-to-face questionnaire with caregivers. We estimated crude and adjusted risk ratios (RR) and 95% confidence intervals (CI) for treatment failure at 48 hours by household use of wood as a cooking fuel. We assessed for effect modification by age (1-5 vs. 6-23 months) and malnutrition (none vs. moderate vs. severe). Results Median age of the 284 enrolled children was 5.9 months and 17% had moderate or severe malnutrition. Ninety-nine (35%) children failed treatment at 48 hours and 17 (6%) died. In multivariable analyses, household use of wood as a cooking fuel increased the risk of treatment failure at 48 hours (RR: 1.44, 95% CI: 1.09-1.92, P=0.01). This association differed by child nutritional status (P=0.02), with a detrimental effect observed only among children with no or moderate malnutrition. Conclusions Exposure to wood smoke worsens outcomes from childhood pneumonia. Efforts to prevent exposure to smoke from unprocessed fuels may improve pneumonia outcomes among children.