RESUMO
Newborn infections are responsible for approximately one-third of the estimated 4.0 million neonatal deaths that occur globally every year...
Assuntos
Humanos , Centros de Saúde , Mortalidade Infantil , Recém-Nascido , PesquisaRESUMO
BACKGROUND: Pneumonia causes more child deaths than does any other disease. Observational studies have indicated that smoke from household solid fuel is a significant risk factor that affects about half the world's children. We investigated whether an intervention to lower indoor wood smoke emissions would reduce pneumonia in children. METHODS: We undertook a parallel randomised controlled trial in highland Guatemala, in a population using open indoor wood fires for cooking. We randomly assigned 534 households with a pregnant woman or young infant to receive a woodstove with chimney (n=269) or to remain as controls using open woodfires (n=265), by concealed permuted blocks of ten homes. Fieldworkers visited homes every week until children were aged 18 months to record the child's health status. Sick children with cough and fast breathing, or signs of severe illness were referred to study physicians, masked to intervention status, for clinical examination. The primary outcome was physician-diagnosed pneumonia, without use of a chest radiograph. Analysis was by intention to treat (ITT). Infant 48-h carbon monoxide measurements were used for exposure-response analysis after adjustment for covariates. This trial is registered, number ISRCTN29007941. FINDINGS: During 29,125 child-weeks of surveillance of 265 intervention and 253 control children, there were 124 physician-diagnosed pneumonia cases in intervention households and 139 in control households (rate ratio [RR] 0·84, 95% CI 0·63-1·13; p=0·257). After multiple imputation, there were 149 cases in intervention households and 180 in controls (0·78, 0·59-1·06, p=0·095; reduction 22%, 95% CI -6% to 41%). ITT analysis was undertaken for secondary outcomes: all and severe fieldworker-assessed pneumonia; severe (hypoxaemic) physician-diagnosed pneumonia; and radiologically confirmed, RSV-negative, and RSV-positive pneumonia, both total and severe. We recorded significant reductions in the intervention group for three severe outcomes-fieldworker-assessed, physician-diagnosed, and RSV-negative pneumonia--but not for others. We identified no adverse effects from the intervention. The chimney stove reduced exposure by 50% on average (from 2·2 to 1·1 ppm carbon monoxide), but exposure distributions for the two groups overlapped substantially. In exposure-response analysis, a 50% exposure reduction was significantly associated with physician-diagnosed pneumonia (RR 0·82, 0·70-0·98), the greater precision resulting from less exposure misclassification compared with use of stove type alone in ITT analysis. INTERPRETATION: In a population heavily exposed to wood smoke from cooking, a reduction in exposure achieved with chimney stoves did not significantly reduce physician-diagnosed pneumonia for children younger than 18 months. The significant reduction of a third in severe pneumonia, however, if confirmed, could have important implications for reduction of child mortality. The significant exposure-response associations contribute to causal inference and suggest that stove or fuel interventions producing lower average exposures than these chimney stoves might be needed to substantially reduce pneumonia in populations heavily exposed to biomass fuel air pollution. FUNDING: US National Institute of Environmental Health Sciences and WHO.
Assuntos
Poluição do Ar em Ambientes Fechados/efeitos adversos , Culinária , Incêndios , Pneumonia/prevenção & controle , Madeira , Poluição do Ar em Ambientes Fechados/prevenção & controle , Monóxido de Carbono/análise , Exposição Ambiental/efeitos adversos , Guatemala/epidemiologia , Humanos , Lactente , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Vigilância da População , Infecções por Vírus Respiratório Sincicial/epidemiologia , Índice de Gravidade de Doença , Fumaça/efeitos adversosRESUMO
Identification of simple signs and symptoms that predict severe illness needing referral for admission of young infants is critical for reducing mortality in developing countries. Infants <2 months of age presenting to two hospitals in La Paz, Bolivia (n=1082) were evaluated by nurses for signs and symptoms, and independently by physicians for the need for admission. In young neonates, sensitivity of individual clinical signs was >35% for measured temperature ≥ 37.5° C (65%); all signs had specificity >85%. Odds ratios (ORs) for association of individual clinical signs with need for urgent hospital management were highest (>5) for history of difficulty feeding, not feeding well and fever. Clinical signs or symptoms are useful for primary healthcare workers to identify young infants with serious illness needing admission, and have been incorporated into the Integrated Management of Childhood Illness algorithm for use in Bolivia and elsewhere in Latin America.