New Results About Childhood Pneumonia from PERCH

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Vaccine Access Digest
October 2021
Johns Hopkins University
Bloomberg School of Public Health

New Results from Landmark PERCH Study on Childhood Pneumonia


The Pneumonia Etiology Research for Child Health (PERCH) study evaluated the etiology of severe and very severe pneumonia in children hospitalized in seven African and Asian countries. Published in The Pediatric Infectious Disease Journal, this latest set of papers focuses on site-specific results and impart important lessons that can inform disease control policies.

Key lessons learned from their findings include:
  • Most causes of severe and very severe pneumonia are viral, and primary prevention policies should be adapted accordingly. However, pneumonia control policies need regional adaptation because there is substantial variation in the fraction of viruses and bacteria causing disease in different regions. 
  • Despite the predominance of viral pneumonia cases estimated by this study, almost all cases involved codetection of multiple pathogens, which could indicate coinfection with more than one pathogen. Sequential viral–bacterial coinfection has been identified elsewhere as a contributor to very severe pneumonia and pneumonia mortality and treatment practices should continue to consider this possibility.  
  • Pneumonia caused by Mycobacterium tuberculosis and Pneumocystis jirovecii can be more common in dense urban settings and practices should tailor prevention and treatment strategies to these pathogens.
  • Several factors increase the likelihood of death from pneumonia in children, especially malnutrition and HIV-infection or exposure.
Exchange visits for investigators and technicians—for example, between South Africa, The Gambia, and Kenya (shown here)—enabled learning and collaboration. (Photo: Maria Deloria Knoll)
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Thanks to Generous Donors to the Johns Hopkins India Initiative, Neeta Accessed a Safe Hospital Delivery


Neeta, a 25-year-old woman who lives in a slum in Delhi, was pregnant and due for delivery in April 2021. The second wave of COVID-19 took everyone by surprise and the government announced a strict lockdown around her due date. Around the 20th of April, Neeta started experiencing labor pains. She went to a government hospital, but due to the alarming number of COVID cases, she was sent back home. Neeta’s husband took her to a private hospital, despite being a daily wage laborer and having limited funds.

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A child gets vaccinated in Delhi (Source: Dr. Rajeev Seth, BUDS).
The COVID-19 pandemic has had devastating consequences on families and societies in India. The  John Hopkins Maternal and Child Health Center India works alongside the Johns Hopkins India Institute, which formed a  COVID-19 Task Force to raise awareness, respond to current needs, and coordinate activities, services, and opportunities to address the COVID-19 pandemic in India.
 
 

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PERCH Publications
 
 
Introduction to the Site-specific Etiologic Results From the Pneumonia Etiology Research for Child Health (PERCH) Study
This paper highlights and summarizes the in-depth site-specific etiology analyses from the Pneumonia Etiology Research for Child Health (PERCH) Study. The studies are published separately in this issue, and explore how etiology varies by age, mortality status, malnutrition, severity, HIV status, and more. 
The Etiology of Childhood Pneumonia in The Gambia: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study
The study of pneumonia at the Gambia PERCH site was in the context of PCV and Hib vaccine use. They investigated the remaining causes of pneumonia in this rural West African setting of high child mortality, high pneumonia incidence, and low HIV prevalence.
The Etiology of Childhood Pneumonia in Mali: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study
The Bamako PERCH site in Mali investigated the high case fatality among children with severe pneumonia, and highlighted a role for new interventions as well as a need to improve vaccine coverage and strengthen healthcare delivery.
The Etiology of Pneumonia in HIV-uninfected Children in Kilifi, Kenya: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study
Researchers investigated the etiology of severe childhood pneumonia in Kenya after introduction of conjugate vaccines against H. influenzae type b, in 2001, and S. pneumoniae, in 2011. They identified respiratory syncytial virus as the main cause of CXR-positive pneumonia.
The Etiology of Pneumonia in Zambian Children: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study
Childhood pneumonia among HIV-uninfected children in Lusaka, Zambia, is most frequently caused by respiratory syncytial virus, M. tuberculosis and human metapneumovirus, and the mortality remains high.
The Etiology of Pneumonia in HIV-infected Zambian Children: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study
HIV-infected children under 5 at the Zambian PERCH study site with severe pneumonia have poor outcomes with continued limited access to care, with the pathogens Pneumocystis jirovecii and M. tuberculosis the predominant etiologies.
The Etiology of Pneumonia in HIV-uninfected South African Children: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study
The etiology of pneumonia amongst HIV-uninfected South African children enrolled into the PERCH case-control study was similar in those born to HIV-infected mothers and uninfected mothers – about a third caused by respiratory syncytial virus. The authors recommend prioritizing vaccination strategies targeting RSV and interventions to address the high TB burden in their setting.
The Etiology of Pneumonia in HIV-1-infected South African Children in the Era of Antiretroviral Treatment: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study
Among children with HIV, bacteremia and in-hospital death were frequent following severe pneumonia episodes at the South African PERCH study site, which were associated with lack of cotrimoxazole prophylaxis and antiretroviral therapy. Investigators found four pathogens contributed a considerable burden of radiologically confirmed pneumonia: Pneumocystis jirovecii, S. aureus, pneumococcus and respiratory syncytial virus.
The Etiology of Childhood Pneumonia in Bangladesh: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study
Two Bangladesh PERCH study sites, one urban and one rural, with moderate child mortality found 97% of their severe pneumonia cases had wheeze, perhaps explained by the preponderance (almost 80%) of virus-attributed etiology, most notably respiratory syncytial virus.
Etiology and Clinical Characteristics of Severe Pneumonia Among Young Children in Thailand: Pneumonia Etiology Research for Child Health (PERCH) Case–Control Study Findings, 2012–2013
Among children with severe pneumonia at two sites in Thailand, RSV was the predominant pneumonia pathogen and TB accounted for 10% of cases. The findings confirmed the need to develop and evaluate RSV prevention strategies that are feasible to implement globally.
 

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