Clinical pneumonia in the hospitalised child in Malawi in the post-pneumococcal conjugate vaccine era: a prospective hospital-based observational study

Abstract

AbstractObjectiveAssess characteristics of clinical pneumonia after introduction of pneumococcal conjugate vaccine (PCV), by HIV exposure status, in children hospitalized in a governmental hospital in Malawi.Methods and findingsWe evaluated 1,139 children ≤5 years old hospitalised with clinical pneumonia: 101 HIV-exposed uninfected (HEU) and 1038 HIV-unexposed, uninfected (HUU). Median age was 11 months (IQR 6-20), 59% were male, median mid-upper arm circumference (MUAC) was 14 cm (IQR 13-15) and mean weight-for-height z score was -0.7 (±2.5). The highest Respiratory Index of Severity in Children (RISC) scores were allocated to 10.4% of the overall cohort, respectively. Only 45.7% had fever, and 37.2% had at least one danger sign at presentation. The most common clinical features were crackles (54.7%), nasal flaring (53.5%), and lower chest wall indrawing (53.2%). Compared to HUU, HEU children were significantly younger (9 months v. 11 months), with lower mean birth weight (2.8 kg v. 3.0 kg) and MUAC (13.6 cm v. 14.0 cm), had higher prevalence of vomiting (32.7% v. 22.0%), tachypnoea (68.4% v. 49.8%), and highest RISC scores (20.0% v. 9.4%). Five children died (0.4%). However, clinical outcomes were similar for both groups.ConclusionsIn this post-PCV setting where prevalence of HIV and malnutrition is high, children hospitalised fulfilling the WHO Integrated Management of Childhood Illness criteria for clinical pneumonia present with heterogeneous features. These vary by HIV exposure status but this does not influence either the frequency of danger signs or mortality. The poor performance of available severity scores in this population and the absence of more specific diagnostics hinder appropriate antimicrobial stewardship and the rational application of other interventions.Strengths and limitations of the studyWe evaluated over 1,100 children hospitalized with pneumonia in a low-income country setting after introduction of PCV.This observational cohort was nested within a prospective hospital-based study of PCV13 effectivenessWe assessed the demographic and clinical characteristics of clinical pneumonia patients and compared HEU vs. HUU children, and computed RISC scores for severe pneumonia