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  • buy AMI5 inhibitor The excellent birth cohort study reported


    The excellent birth cohort study reported in by Heather Zar and colleagues, done in a periurban area outside Cape Town in South Africa, is a good example of a study that has provided important information about child pneumonia at a time of change. It provides the first incidence estimates of pneumonia and severe pneumonia in a low-to-middle-income country (LMIC) population, with high coverage of both (13 valent) pneumococcal and type b conjugate vaccines, and with roughly a fifth of the cohort being HIV-exposed but uninfected. On a background of falling pneumonia incidence over the past decade, these estimates show that, despite an effective buy AMI5 inhibitor programme addressing the two major causes of pneumonia death, pneumonia continues to be a major burden on health services in this South African population. Worldwide, it remains a major cause of care-seeking for child illness, attendance at clinics, admission to hospital, and prescription of antibiotics. This study suggests that the modelled annual incidence estimates for South Africa in 2010, using a risk factor model that included HIV, of 0·22 episodes in children aged younger than 5 years, are broadly consistent with estimates reported in Theodoratou and colleagues\' study. This finding would equate to 1·12 million new cases in South Africa each year in this age group. Although pneumococci and type b are major causes of child death from pneumonia, they account for a small proportion of overall pneumonia episodes and hence, as Zar and colleagues point out, continuing investment in social determinants of pneumonia and scaling up of the coverage of other known effective interventions is needed. This investment should also give priority to cross-sectoral approaches, with action on determinants such as maternal education, with appropriate attention given to address the problems of minority and disadvantaged populations. Investment in innovation to tackle other important causes of the remaining pneumonia burden, such as respiratory syncytial virus and influenza, is also needed. The study also points out some other important aspects of the pneumonia burden. Increasingly, the major pneumonia burden is in the first 2 years of life (rather than the international focus on children aged younger than 5 years). Additionally, severe pneumonia accounting for most pneumonia deaths occurs in the first 6 months of life (in this study 26 of 32 of severe episodes had occurred by age 2 months), which might need increasing attention in programme-priority setting. As part of an epidemiological transition accompanying the trends reported here, wheeze is an increasingly important presentation in children presenting with cough and difficulty breathing (reported in 65% of cases in this study), which merits further research to reduce antibiotic over-treatment and promote correct treatment of wheeze in these children. The male to female incidence ratio of 2:1 is substantially larger than the established (slight) increased pneumonia risk due to so-called biological frailty in boys and points to the need to explore possible gender discrimination in care-seeking. Although the study reports an active surveillance system, this system is in fact an active case ascertainment within an essentially passive surveillance system, which could have led to missed cases (when care was not sought) and differential care-seeking by gender. Alarming levels of differential hospital admissions of children with pneumonia by gender have been reported in some LMICs. If the full effect of effective interventions against childhood pneumonia is to be realised, then gender discrimination in some countries needs to be recognised as a major source of inequity in child health. Reporting of child health data by sex, as in this study, needs to be seen as an essential element of good practice in the reporting of child health data so that attention can be drawn to sex discrimination, where it exists.
    In , Sabine Dittrich and colleagues report that scrub typhus caused by , murine typhus caused by , and leptospirosis caused by various species account for more than a third of CNS infections diagnosed over 8 years in Vientiane Hospital in Laos. The study is one more great contribution from this team in their investigation of undocumented syndromes, as well as in the public health challenge of rickettsial diseases in southeast Asia. The same investigators have previously reported that scrub typhus was the second most common microbial cause of fever of unknown origin in rural Laos (122 [15%] of 799 diagnosed cases). In 2006, rickettsial infection was detected in 115 (27%) of 427 adults admitted to Vientiane Hospital for fever with negative blood culture. The most common rickettsial agent was followed by . Fewer data are available about the prevalence of these diseases in other southeast Asian countries. In Thailand, scrub and murine typhus has been reported in 16% and 2%, respectively, of fever of unknown origin, with mortality of 3–17% for scrub typhus. Even if epidemiological data for the whole region are unavailable, the substantial presence of rickettsial infections is shown by frequent reports in travellers returning from this area. Because ecotourism and adventure travel are increasingly popular, the incidence of tick-borne rickettsioses among travellers is likely to continue to increase.