Community-Acquired Pneumonia in Children: Quantifying the Burden on Patients and Their Families Including Decrease in Quality of Life Yaron Shoham, Ron Dagan, Noga Givon-Lavi, Zvika Liss, Tomer Shagan, Orly Zamir and David Greenberg Pediatrics 2005;115;1213-1219 DOI: 10.1542/peds.2004-1285

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/115/5/1213

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2005 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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䡠䡠 䡠䡠 䡠䡠 䡠䡠 May 2005 䡠䡠 VOL. 115 䡠䡠 NO. 5 䡠䡠

Community-Acquired Pneumonia in Children: Quantifying the Burden on Patients and Their Families Including Decrease in Quality of Life Yaron Shoham, BMedSc*; Ron Dagan, MD*; Noga Givon-Lavi, PhD*; Zvika Liss, MD‡; Tomer Shagan, PhD*; Orly Zamir*; and David Greenberg, MD* ABSTRACT. Objectives. Childhood respiratory infections have an important impact on society and are a frequent cause of physician visits, consumption of antibiotics and over-the-counter drugs, work loss, and reduction of quality of life. The aim of this study was to assess the burden of community-acquired pneumonia (CAP) on children and their families, including quantification of expenses and decrease in quality of life. Methods. Patients <3 years old with pneumonia were enrolled in 3 sites in southern Israel: pediatric wards, the pediatric emergency department, and a primary health clinic. In the primary health clinic, the diagnosis was based on clinical judgment, and in the hospital the diagnosis was based on the World Health Organization Standardization of Interpretation of Chest Radiographs for the diagnosis of CAP in children. Data regarding the children’s medical history and various aspects of direct and indirect burden were gathered every 2 to 3 days during the 29 days of follow-up. The patients’ parents were asked to give the names of 2 healthy children who could serve as controls from among the child’s friends, neighbors, or day care center attendees. Results. Two-hundred thirteen children with pneumonia were enrolled: 34 (16.0%) in the pediatric wards, 73 (34.2%) in the pediatric emergency department, and 106 (49.8%) in the primary pediatric clinic. The control group consisted of 99 children. During the 29 follow-up days, hospitalized children had the most severe and prolonged symptoms, followed in decreasing order by children seen at the emergency department, primary health clinic, and controls: The mean ⴞ standard deviation (SD) of febrile From the *Pediatric Infectious Disease Unit, Soroka University Medical Center, ‡Israeli General Health Insurance Plan, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Accepted for publication Sep 29, 2004. This article was submitted in partial fulfillment of the requirements for the doctor of medicine degree by Mr Shoham. doi:10.1542/peds.2004-1285 No conflict of interest declared. Address correspondence to David Greenberg, MD, Pediatric Infectious Disease Unit, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer-Sheva 84105, Israel. E-mail: [email protected] PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Academy of Pediatrics.

days was 4.9 ⴞ 2.8, 4.8 ⴞ 3.1, 3.3 ⴞ 2.5, and 1.4 ⴞ 3.3, respectively (statistically significant between any patient group and the control group). The mean duration of respiratory distress ⴞ SD was 3.8 ⴞ 5.6, 2.8 ⴞ 4.4, 2.2 ⴞ 4.4, and 0.4 ⴞ 1.8 days, respectively (statistically significant between any patient group and the control group). The median duration of nonroutine days as judged by the parents was 13, 8, 7, and 0, respectively. The mean number of workdays lost by working mothers ⴞ SD was 4.2 ⴞ 4.8, 2.0 ⴞ 2.6, 1.7 ⴞ 1.9, and 0.2 ⴞ 0.9, respectively (between any patient group and the control group). The quality-of-life– questionnaire analysis reveals statistically significant differences with regard to all 11 questions asked between any of the patient groups and the control group. There was a clear trend toward decreasing quality of life from the control group to the primary health clinic, pediatric emergency department, and pediatric wards groups. Conclusions. CAP in children causes a significant burden on both patients and their families, including substantial expenses, loss of routine, and decrease in quality of life. Pediatrics 2005;115:1213–1219; pneumonia, children, burden, quality of life. ABBREVIATIONS. CAP, community-acquired pneumonia; ENT, otorhinolaryngologic; NIS, new Israeli shekels.

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ommunity-acquired pneumonia (CAP) is a common and potentially serious infection afflicting children throughout the world, especially those ⬍5 years old, the age group in which the annual incidence reaches 34 to 40 cases per 1000 in Europe and North America. In the developing world, CAP is more common and more severe and is the largest killer of children.1 Childhood community-acquired infections have an important impact on society and are a frequent cause of physician visits, consumption of antibiotics and over-the-counter drugs, work loss, and reduction of quality of life.2 The direct cost of an episode of pneumonia may be measured by physician visits, the

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cost of a chest radiograph, and consumption of antibiotics and over-the-counter drugs. The indirect costs such as missing work to care for a sick child, hiring a babysitter, and transportation costs are more difficult to assess. Surveys to assess these costs were conducted with regard to infant vaccines3 and common infections in toddlers attending day care center.4 Beyond financial considerations, one can anticipate that an episode of pneumonia may have an impact on the quality of life of patients and their families, including the daily family organization, the social activities, stress, and anxiety of the parents as seen in recurrent otorhinolaryngologic (ENT) infections,5 and the patient’s symptoms. Surveys to assess the patients’ or families’ quality of life in childhood illnesses were conducted with regard to several childhood illnesses5–11 through the use of a specific quality-of-life questionnaire devised to assess different parameters specific to the illness being studied. To the best of our knowledge, such a survey has not been conducted with regard to childhood CAP, and a specific quality-oflife questionnaire has not been devised and validated. The quality-of-life questionnaire for recurrent ENT infections was devised based on a literature search regarding existing quality-of-life questionnaires for parents in childhood illnesses and meetings with parents of children who were suffering from recurrent ENT infections and was reviewed by a pediatrician.5 We estimated this questionnaire to be a suitable basis for devising a questionnaire for childhood CAP, because it was the only one found by our group at the time that dealt with childhood respiratory disease. The aim of this study was to assess the burden of CAP on children and their families, including quantification of expenses and decrease in quality of life. PATIENTS AND METHODS Enrollment Patients were enrolled in 3 sites in Beer-Sheva, Israel: the Soroka University Medical Center pediatric wards, the pediatric emergency department, and a pediatric primary health clinic. Research assistants were present at the primary care clinic every workday for 4 hours to enroll patients. Patients in the pediatric wards and pediatric emergency department groups were enrolled by research assistants either on site or by phone. The Soroka University Medical Center is the major hospital of the Negev area of Israel. The study primary health clinic in Beer-Sheva also serves as a referral clinic of ⬃60% of the city’s pediatric population and is the major clinic at which chest radiographs are performed.

Inclusion Criteria Patients diagnosed as having pneumonia were enrolled if: (1) they were ⬍3 years old; (2) their parents had an available phone connection; (3) their parents were fluent in the Hebrew language; (4) they were not participating concurrently in another clinical survey or trial; (5) they did not have any known chronic, progressive, or oncologic illnesses (except for asthma); and (6) parents or legal guardians signed an informed consent. For patients enrolled in the primary health clinic, the diagnosis was based on a chest radiograph having been ordered according to the clinical judgment of the primary physician based on clinical signs and symptoms of pneumonia (regardless of the interpretation of the radiograph). In the hospital, patients presenting with clinical signs and symptoms of pneumonia underwent a chest radiograph, and diagnosis was based on the World Health Organization Standardization of Interpretation of Chest Radiographs for the diagnosis of

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CAP in children.12 Controls were enrolled if they did not suffer from pneumonia at enrollment and were excluded if they had pneumonia during the follow-up period.

Initial Data Collection The initial questionnaire included the following variables: age, gender, chronological order of child in the family, total number of persons living at home, number of bedrooms, number of people sleeping with the child in the same room, child’s and siblings’ day care attendance, and the number of children in the day care attended by the child or the child’s sibling(s). Mother’s and father’s age, workplace, information on employment, and years of schooling also were recorded. In addition, variables regarding the medical history of the child were gathered, such as respiratory distress at birth, known allergies, pneumonia episodes, asthma attacks, acute otitis media infections, hospitalizations, and antibiotic-treatment episodes.

Controls At the end of the initial questionnaire, the patient’s parents were asked to give the names of 2 optional children that were currently healthy and would be fit to serve as part of the control group from among the child’s friends, neighbors, and day care center attendees.

Follow-up After completion of the initial questionnaire, telephone interviews were performed every 2 to 3 days for a total of 21 days of follow-up after the initial visit day (total follow-up was actually 29 days, because questions about the 7 days before the initial visit day were also included). The follow-up questionnaire was designed to obtain details on the daily occurrence of fever, cough, respiratory distress (according to the parents’ subjective interpretation), diarrhea, vomiting, restlessness and crying, sleepiness, decline in appetite, sleep disturbances, and whether the parents regarded the day to be a routine or nonroutine day for the child compared with the child’s activity and symptoms before the episode of pneumonia. Details on the daily occurrence of a parent or caregiver missing work to care for the child, hiring a babysitter to care for the child, visits to the primary physician, nurse, emergency department, or other health-related provider(s), the length of the visit(s) (including time spent on transportation), transportation expenses (or number of kilometers) for the visit(s), and expenses for private house calls, specialists, medications, or radiographs were also obtained.

Quality-of-Life Questionnaire To quantify the parents’ quality of life during the pneumonia episode, a questionnaire designed for parents’ quality of life in regards to recurrent ENT infections was used.5 We translated the English questionnaire to Hebrew and used 11 of the original 18 questions, which we thought were appropriate for an episode of pneumonia in Israel. The parents were asked to fill in the questionnaire at the end of the 21-day follow-up period or earlier if they deemed the child to have returned to routine life before the end of the follow-up period. Responses to the questions were given by the major caregiver parent according to a scale of 1 to 5 (1: not at all; 5: very much so). The questions regarded the extent of the parent’s worrying, stress, annoyance, helplessness, sleep quality affected, having less time available for other family members, leisure restriction, perceiving the illness to be a source of quarrel in the family, repercussions on his or her own health, losing morale, and overall impact on quality of life due to the child’s medical situation. The parents were also asked to estimate the total out-of-pocket expenses for the child’s health during the follow-up period.

Data Analysis Data were recorded by using Access software (Microsoft, Seattle, WA), and statistical analysis was performed by using SPSS software (SPSS Inc, Chicago, IL). Continuous variables were compared by the 1-way analysis of variance procedure with Bonferroni post hoc range tests for pairwise multiple comparisons. Categorical variables were tested by the ␹2 test or Fischer’s exact test

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as appropriate. The means of ordinal data were compared by using the Kruskal-Wallis 1-way analysis of variance.

RESULTS

Between October 12, 2000, and June 24, 2001, 319 children were enrolled in the study, of whom 7 (2.2%) were lost to follow-up and did not complete the study. The final study group included 213 children, of whom 34 (16.0%) were enrolled in the pediatric wards, 73 (34.2%) in the pediatric emergency department, and 106 (49.8%) in the primary health clinic. A total of 99 control children were recruited. There were no significant differences between the groups with regard to age, gender, parents’ age, and medical history (Table 1). A trend toward larger family size, more people sleeping in the same room with the subject, number of subjects attending a day care center, and number of children attending a day care center with the subject, suggesting increased crowding among children with CAP compared with controls, was found. Patients who were treated in the hospital for CAP had a significantly higher number of people in the household and more persons sleeping in the same room with the child than controls. An increase in the mean number (⫾SD) of persons sleeping in the same room as the index case was found moving from controls to what can be considered milder cases (primary health clinic), to more severe cases (pediatric emergency department), and to most severe cases (pediatric wards): 1.8 ⫾ 0.9, 2.0 ⫾ 0.8, 2.3 ⫾ 0.9, and 2.4 ⫾ 0.8, respectively (Table 1). The mean number of persons in the household were 4.2 ⫾ 1.2, 4.4 ⫾ 1.3, 5.3 ⫾ 2.2, and 5.1 ⫾ 1.9, respectively. A trend toward a decrease in parental education was also observed, reaching significance with mean father’s schooling years: 14.0 ⫾ 4.0, 12.3 ⫾ 3.8, 12.7 ⫾ 3.3, and 12.1 ⫾ 3.5, respectively.

During the follow-up period, patients experienced a significantly higher number of days of illness compared with the controls (Table 2). The trend toward increased duration through the groups was seen regarding the mean number of days of absenteeism from day care centers as well. The duration of hospitalization for the hospitalized group was 4.7 ⫾ 2.9 days. A trend toward increased duration of symptoms from the control group and through the primary health clinic, pediatric emergency department, and pediatric wards groups was observed also (Fig 1). The trend shown above could be seen also with regard to the proportion of the child’s nonroutine days as judged by the caregivers during the follow-up period (Fig 2). The median duration of nonroutine days as judged by the parents was 0, 7, 8, and 13 for the control, primary health clinic, pediatric emergency department, and pediatric wards groups, respectively. At the end of the follow-up period (day 21), 14% of the primary health clinic group patients, 25% of the pediatric emergency department group patients, and 15% of the pediatric wards group patients were still experiencing a nonroutine day in comparison with only 3% of the controls (P ⬍ .001 between the pediatric emergency department and control groups). The burden of the families during the follow-up period (Table 3) can be divided into loss of working days and time and out-of-pocket expenses. Working mothers lost 0.2 ⫾ 0.9, 1.7 ⫾ 1.9, 2.0 ⫾ 2.6, and 4.2 ⫾ 4.8 days for the control, primary health clinic, pediatric emergency department, and pediatric wards groups, respectively (Table 3). The out-of-pocket expenses showed a similar trend. The parents’ subjective estimate of the total expenses for the child’s medical condition throughout the follow-up period

TABLE 1. Demographic Characteristics and Medical History of the Patients Enrolled in the Pediatric Wards, Pediatric Emergency Department, and Pediatric Primary Health Clinic and Controls Selected Characteristics

Pediatric Wards (n ⫽ 34)

Pediatric Emergency Department (n ⫽ 73)

Primary Health Clinic (n ⫽ 106)

Controls (n ⫽ 99)

P Value

Mean age of patient/control ⫾ SD, mo Percentage of males (n) Mean no. of bedrooms in house ⫾ SD Mean no. of persons in household ⫾ SD Mean no. of persons sleeping with child ⫾ SD Mean no. of children attending day care center together with child ⫾ SD§ Mean mothers’ age ⫾ SD, y Mean fathers’ age ⫾ SD, y Mean mothers’ years of schooling ⫾ SD Mean fathers’ years of schooling ⫾ SD Percentage of mothers working out of home (n) Percentage of fathers working out of home (n) Percentage of patients or controls attending day care centers (n) Mean no. of pneumonia episodes during past year ⫾ SD Mean no. of asthma attacks since birth ⫾ SD

18.4 ⫾ 8.7 62 (21) 2.9 ⫾ 1.0 5.1 ⫾ 1.9 2.4 ⫾ 0.8 11.7 ⫾ 10.2

19.2 ⫾ 8.7 48 (35) 3.1 ⫾ 1.2 5.3 ⫾ 2.2 2.3 ⫾ 0.9 12.6 ⫾ 10.4

19.5 ⫾ 9.2 49 (52) 2.8 ⫾ 1.1 4.4 ⫾ 1.3 2.0 ⫾ 0.8 12.7 ⫾ 11.2

19.0 ⫾ 9.4 NS 51 (50) NS 3.0 ⫾ 1.1 NS 4.2 ⫾ 1.2 ⬍.001*†‡ 1.8 ⫾ 0.9 ⬍.001*† 9.8 ⫾ 10.2 NS

30.2 ⫾ 5.5 31.5 ⫾ 9.6 13.1 ⫾ 2.1 12.1 ⫾ 3.5 68 (23) 92 (31) 65 (22)

31.4 ⫾ 5.7 35.2 ⫾ 7.5 13.4 ⫾ 4.2 12.7 ⫾ 3.3 69 (50) 90 (66) 65 (47)

31.1 ⫾ 5.8 32.5 ⫾ 9.7 13.5 ⫾ 2.4 12.3 ⫾ 3.8 77 (82) 85 (90) 67 (71)

30.8 ⫾ 4.8 32.1 ⫾ 8.2 14.6 ⫾ 3.0 14.0 ⫾ 4.0 81 (80) 93 (92) 54 (53)

0.44 ⫾ 1.01

0.34 ⫾ 0.72

0.17 ⫾ 0.41

0.13 ⫾ 0.39

NS

1.00 ⫾ 2.82

0.76 ⫾ 2.01

1.89 ⫾ 4.15

0.60 ⫾ 1.71

NS

NS NS NS .004储 NS NS NS

NS indicates nonsignificant. * Statistically significant between the pediatric wards and control groups. † Statistically significant between the pediatric emergency department and control groups. ‡ Statistically significant between the pediatric emergency department and primary health clinic groups. § For those attending day care center only. 储 Statistically significant between the primary health clinic and control groups.

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TABLE 2. Quality-of-Life Decrease in Children With Pneumonia Enrolled in the Pediatric Wards, Pediatric Emergency Department, and Pediatric Primary Health Clinic and Controls

Mean no. of days Mean no. of days Mean no. of days Mean no. of days Mean no. of days Mean no. of days Mean no. of days Mean no. of days center ⫾ SD¶

of hospitalization ⫾ SD of cough ⫾ SD of diarrhea ⫾ SD of vomiting ⫾ SD of crying ⫾ SD with decreased appetite ⫾ SD with decreased sleep ⫾ SD of absenteeism from day care

Pediatric Wards (n ⫽ 34)

Pediatric Emergency Department (n ⫽ 73)

Primary Health Clinic (n ⫽ 106)

Controls (n ⫽ 99)

P Value

4.7 ⫾ 2.9 11.6 ⫾ 8.2 1.5 ⫾ 3.8 2.1 ⫾ 3.3 6.1 ⫾ 5.3 8.5 ⫾ 5.4 4.5 ⫾ 5.6 7.5 ⫾ 5.6

0.2 ⫾ 1.2 10.5 ⫾ 6.6 0.8 ⫾ 1.8 1.3 ⫾ 1.9 6.3 ⫾ 5.0 8.7 ⫾ 6.3 4.3 ⫾ 5.6 4.4 ⫾ 4.1

0.1 ⫾ 0.4 11.8 ⫾ 6.9 1.0 ⫾ 2.8 1.6 ⫾ 2.7 5.4 ⫾ 4.8 7.6 ⫾ 6.1 5.8 ⫾ 6.1 3.7 ⫾ 3.3

0 2.4 ⫾ 4.9 0.01 ⫾ 0.1 0.2 ⫾ 1.0 0.9 ⫾ 2.1 1.0 ⫾ 2.8 0.5 ⫾ 1.6 0.5 ⫾ 1.4

⬍.001*†‡ ⬍.001*§储 .001*储 ⬍.001*§储 ⬍.001*§储 ⬍.001*§储 ⬍.001*§储 ⬍.001*†‡§储

* Statistically significant between the pediatric wards and control groups. † Statistically significant between the pediatric wards and pediatric emergency department groups. ‡ Statistically significant between the pediatric wards and primary health clinic groups. § Statistically significant between the pediatric emergency department and control groups. 储 Statistically significant between the primary health clinic and control groups. ¶ For those attending day care center only.

Fig 1. Mean number of days with clinical signs and symptoms. *, statistically significant between the pediatric wards and control groups; †, statistically significant between the pediatric emergency department and control groups; ‡, statistically significant between the primary health clinic and control groups; §, statistically significant between the pediatric wards and primary health clinic groups; 㛳, statistically significant between the pediatric emergency department and primary health clinic groups.

also shows the same trend: 33 ⫾ 99, 448 ⫾ 509, 747 ⫾ 1198, and 976 ⫾ 641 new Israeli shekels (NIS; during the study period, exchange rates were ⬃1 NIS ⫽ 0.24 US dollars) for the control, primary health clinic, pediatric emergency department, and pediatric wards groups, respectively (Table 3). The quality-of-life questionnaire analysis reveals statistically significant differences with regard to all 11 questions asked between any of the patient groups and the control group (Table 4). These differences also show a clear increasing trend from control group to the primary health clinic, pediat1216

ric emergency department, and pediatric wards groups. DISCUSSION

The aim of the present prospective study was to determine the direct burden of childhood CAP on patients and their families during a 1-month time period. The study was conducted in the southern region of Israel among the Hebrew-speaking population, which is comparable to a low- to midsocioeconomic class in a developed country. In this study, patients and controls enrolled were of the same age

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Fig 2. Comparison of nonroutine days during a 1-month follow-up among children with CAP enrolled in pediatric wards, pediatric emergency department, and primary health clinic and controls. Days ⫺1 to ⫺7 indicate days before enrollment; day 0, day of enrollment; days 1 to 21, days of follow-up. TABLE 3. Burden on Families: Financial Burden, Workdays, and Time Loss in Families of Children With Pneumonia Enrolled in the Pediatric Wards, Pediatric Emergency Department, and Pediatric Primary Health Clinic and Controls

Mean no. of medical visit hours ⫾ SD Mean no. of days of work loss by mothers ⫾ SD Mean no. of days of work loss by fathers ⫾ SD Mean no. of days of using a babysitter ⫾ SD Mean distance (in km) of transit by private transportation to medical visits ⫾ SD Mean expense (in NIS) on public transit to medical visits ⫾ SD Mean expense (in NIS) on medications ⫾ SD Mean expense (in NIS) on private medical visits ⫾ SD Total expenses (in NIS) of child’s medical situation (subjective to parent’s estimate)

Pediatric Wards (n ⫽ 34)

Pediatric Emergency Department (n ⫽ 73)

Primary Health Clinic (n ⫽ 106)

Controls (n ⫽ 99)

P Value

6.9 ⫾ 13.9 4.2 ⫾ 4.8 0 1.2 ⫾ 3.9 52.3 ⫾ 62.4

9.2 ⫾ 8.9 2.0 ⫾ 2.6 0.01 ⫾ 0.1 1.8 ⫾ 4.4 24.5 ⫾ 40.0

5.5 ⫾ 9.0 1.7 ⫾ 1.9 0.1 ⫾ 0.5 1.4 ⫾ 3.6 17.0 ⫾ 27.0

1.4 ⫾ 4.7 0.2 ⫾ 0.9 0 1.5 ⫾ 5.6 3.0 ⫾ 11.0

⬍.001*†‡ ⬍.001*†‡§储 NS NS ⬍.001*†‡§储

34.6 ⫾ 90.6

29.9 ⫾ 57.3

10.1 ⫾ 22.3

0.9 ⫾ 6.7

⬍.001*†储¶

45.2 ⫾ 52.3 6.2 ⫾ 23.5 976 ⫾ 641

60.1 ⫾ 101.5 30.7 ⫾ 72.7 747 ⫾ 1198

33.3 ⫾ 37.4 3.9 ⫾ 21.8 448 ⫾ 509

8.2 ⫾ 25.1 0.7 ⫾ 3.9 33 ⫾ 99

⬍.001*†‡¶ ⬍.001†§¶ ⬍.001*†‡储¶

NIS indicates new Israeli shekel; NS, nonsignificant. * Statistically significant between the pediatric wards and control groups. † Statistically significant between the pediatric emergency department and control groups. ‡ Statistically significant between the primary health clinic and control groups. § Statistically significant between the pediatric wards and pediatric emergency department groups. 储 Statistically significant between the pediatric wards and primary health clinic groups. ¶ Statistically significant between the pediatric emergency department and primary health clinic groups.

group and from the same geographic area. This approach allowed us to determine our population’s baseline of events, such as parents’ workdays loss, that were not related directly to the pneumonia episode. Comparison between patients and controls with regard to each event shows the actual contribution of pneumonia to the burden of disease. Furthermore, we divided our patients into 3 groups according to the place of enrollment, which allowed us to assess the differences in the burden of the disease according to the patient’s initial location of care,

reflecting initial severity. To the best of our knowledge, no other study has been conducted by using such a comparison. CAP is often a complication of a viral upper respiratory tract infection.13 As such, a part of the morbidity and burden described in the study could not be distinguished from that of the preceding upper respiratory tract infection, and thus, the specific burden and morbidity attributable to pneumonia per se could not be determined. We could have used an additional control arm of those with upper respira-

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TABLE 4. Quality of Life Mean Score (⫾ SD) of Children With Pneumonia Enrolled in the Pediatric Wards, Pediatric Emergency Department, and Pediatric Primary Health Clinic and Controls

Worry Stress Less patience Sleep quality affected Less time for family Leisure restriction Helplessness Repercussions on parents’ health Source of quarrel within family Morale affected Overall quality-of-life decrease

Pediatric Wards (n ⫽ 34)

Pediatric Emergency Department (n ⫽ 73)

Primary Health Clinic (n ⫽ 106)

Controls (n ⫽ 99)

P Value*

4.6 ⫾ 0.7 4.2 ⫾ 1.2 3.7 ⫾ 1.3 4.1 ⫾ 1.1 3.9 ⫾ 1.2 4.8 ⫾ 0.7 3.8 ⫾ 1.3 2.5 ⫾ 1.6 2.5 ⫾ 1.5 3.9 ⫾ 1.3 3.4 ⫾ 1.5

4.3 ⫾ 0.9 3.9 ⫾ 1.3 3.1 ⫾ 1.3 3.4 ⫾ 1.5 3.4 ⫾ 1.5 4.4 ⫾ 1.0 2.9 ⫾ 1.4 2.0 ⫾ 1.3 2.0 ⫾ 1.2 3.6 ⫾ 1.3 2.7 ⫾ 1.4

3.9 ⫾ 1.0 3.4 ⫾ 1.3 2.8 ⫾ 1.3 3.3 ⫾ 1.4 3.1 ⫾ 1.4 4.1 ⫾ 1.4 2.5 ⫾ 1.5 1.9 ⫾ 1.2 2.0 ⫾ 1.1 3.2 ⫾ 1.3 2.6 ⫾ 1.4

1.5 ⫾ 1.1 1.4 ⫾ 1.0 1.3 ⫾ 0.8 1.5 ⫾ 1.0 1.3 ⫾ 0.9 1.6 ⫾ 1.2 1.3 ⫾ 0.8** 1.1 ⫾ 0.5†† 1.1 ⫾ 0.5†† 1.3 ⫾ 0.9‡‡ 1.2 ⫾ 0.6††

⬍.001†‡§储¶ ⬍.001†‡§储¶ ⬍.001†‡§储# ⬍.001†‡§储# ⬍.001†‡§储 ⬍.001†‡§储# ⬍.001†‡§储# ⬍.001†‡§ ⬍.001†‡§ ⬍.001†‡§储¶ ⬍.001†‡§储#

* According to the Kruskal-Wallis test. † Statistically significant between the pediatric wards and control groups. ‡ Statistically significant between the pediatric emergency department and control groups. § Statistically significant between the primary health clinic and control groups. 储 Statistically significant between the pediatric wards and primary health clinic groups. ¶ Statistically significant between the pediatric emergency department and primary health clinic groups. # Statistically significant between the pediatric wards and pediatric emergency department groups. ** n ⫽ 94. †† n ⫽ 80. ‡‡ n ⫽ 83.

tory infection without pneumonia, but whether the manifestations of some viral infections are similar to those preceding pneumonia is not clear. We divided our findings into 2 separate categories: the burden of pneumonia on the patient and the burden of the disease on the family. With regard to the burden of pneumonia on the patient, during the 1-month follow-up, children with pneumonia experienced more days with the following signs and symptoms than controls: fever, respiratory distress, lethargy, sleepiness, cough, diarrhea, vomiting, crying, loss of appetite, and insomnia. These results are similar to previous reports on signs and symptoms during an episode of childhood pneumonia.13–15 The duration of signs and symptoms resembled the patients’ decreased quality of life in other respiratory diseases such as acute otitis media.2 An important overall measurement of decrease in quality of life by patients is the number of days judged by the parents to be nonroutine days. This parameter not only includes objective measurements such as absenteeism from the day care center or hospitalization but also days when the only measurement is the subjective impression of the parents as reported previously for acute otitis media.2 A trend for increasing numbers of nonroutine days was seen, with the lowest number in the primary health clinic group, a higher number in the emergency department group, and the highest number in the hospitalized group, whereas in the control group it was significantly lower compared with all the groups. Even after 29 days, between 14% and 25% of patients were still experiencing nonroutine days, compared with only 3% of the controls. These findings are similar to those found when nonroutine days were studied for acute otitis media episodes performed in the same population.2 This finding may represent a long-term behavioral problem associated with respi1218

ratory disease, residual symptoms, or emotional disturbances. With regard to the financial burden on families, the patients’ families had considerable out-of-pocket expenses (eg, medications, private medical visits, and transit to medical visits). Indirect expenses (eg, time loss and workdays lost) are also part of the financial burden. The patients’ working mothers lost an average of 2.5 additional workdays compared with mothers in the control group. The expenses of transit to medical visits and loss of workdays were found to be the major component of parental costs during a respiratory syncytial virus infection as well.16 Aside from loss of workdays, the patients’ family members lost additional time during medical visits and public or private transit to medical visits. The costs associated with caring for a sick child (by a family member) may be underestimated. The time necessary to care for the patient could have been used by the caregiver for market work, nonmarket household work, or for leisure.4,17 A calculation of the total financial burden is beyond the scope of this article, but the total household expenses for the child’s medical condition declared by the patients’ parents was estimated to be 415 to 943 NIS ($101–230 US), which is more than that declared by the controls’ parents. At the time this study was conducted, the average net income per family was ⬃8500 NIS according to the Israeli Central Bureau of Statistics,18,19 thus making the parents’ estimates ⬃5% to 11% of the average net income per family. A trend toward increasing severity of signs and symptoms, increasing number of nonroutine days, and increasing out-of-pocket expenses from the control group through the primary health clinic, pediatric emergency department, and pediatric wards groups was observed. The gradual increment of these variables in the 3 patient groups reflects the

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burden of the disease and the direct correlation between this burden and the severity of the disease. When considering any modalities for reducing or modifying CAP in children, these findings should also be taken into consideration. With regard to responses to all 11 questions regarding parents’ quality of life, the average score was lowest in the control group, increased in the primary health clinic and emergency department groups, and was the highest in the hospitalized group. Statistically significant differences were found between any of the patient groups and the control group in all 11 questions. In the majority of cases, statistically significant differences were found between the patient groups as well, thus strengthening the concept of the trend. Although not verified for childhood CAP before our using it, this questionnaire had already undergone verification for another childhood respiratory disease (recurrent ENT infections) and thus was deemed appropriate. Our study had 1 major limitation. In contrast with patients who were diagnosed in the hospital according to radiograph analysis, diagnoses in the primary health clinic were based on the clinical judgment of the primary physicians and were not verified by investigators, nor were they supported by radiograph analysis. In a study conducted in northern California, the 7-valent pneumococcal conjugated vaccine efficacy for CAP in children was calculated for various end points. The first 2 end points were clinical diagnosis of pneumonia and clinical diagnosis of CAP with radiograph ordered by the primary physician. The third and fourth end points were any abnormalities in the chest radiograph and alveolar consolidation, respectively.20 In this study, to be able to quantify the burden on different patient groups we chose to include a group of CAP patients diagnosed in the community based on the clinical diagnosis of CAP with radiograph ordered by the primary physician (similar to the second end point of the California study) in addition to 2 groups diagnosed in the hospital based on the World Health Organization Standardization of Interpretation of Chest Radiographs for the diagnosis of CAP in children (similar to the fourth end point of the California study). In addition, most diagnoses done in the community are based on clinical criteria, thus rending this limitation a part of acceptable medical practice. A pneumococcal conjugate vaccine was introduced recently into several developed countries’ schedules. This vaccine may reduce the incidence and severity of pneumonia in children.21–25 In addition, viral vaccines such as those against influenza (already in use) and respiratory syncytial viruses (which may be introduced in the future) may also have an effect on childhood pneumonia. The utilization of these vaccines by decision makers according to cost-benefit analyses should take into consideration the burden of childhood CAP on patients and their families. REFERENCES 1. McIntosh K. Community-acquired pneumonia in children. N Engl J Med. 2002;346:429 – 437

2. Greenberg D, Bilenko N, Liss Z, Shagan T, Zamir O, Dagan R. The burden of acute otitis media on the patient and the family. Eur J Pediatr. 2003;162:576 –581 3. Lieu TA, Black SB, Ray GT, Martin KE, Shinefield HR, Weniger BG. The hidden costs of infant vaccination. Vaccine. 2000;19:33– 41 4. Carabin H, Gyorkos TW, Soto JC, Penrod J, Joseph L, Collet JP. Estimation of direct and indirect costs because of common infections in toddlers attending day care centers. Pediatrics. 1999;103:556 –564 5. Berdeaux G, Hervie C, Smajda C, Marquis P. Parental quality of life and recurrent ENT infections in their children: development of a questionnaire. Rhinitis Survey Group. Qual Life Res. 1998;7:501–512 6. Landgraf JM, Abidari J, Cilento BG Jr, Cooper CS, Schulman SL, Ortenberg J. Coping, commitment, and attitude: quantifying the everyday burden of enuresis on children and their families. Pediatrics. 2004;113:334 –344 7. Gorelick MH, Brousseau DC, Stevens MW. Validity and responsiveness of a brief, asthma-specific quality-of-life instrument in children with acute asthma. Ann Allergy Asthma Immunol. 2004;92:47–51 8. Gringeri A, von Mackensen S, Auerswald G, et al. Health status and health-related quality of life of children with haemophilia from six West European countries. Haemophilia. 2004;10(suppl 1):26 –33 9. Mansfield LE, Diaz G, Posey CR, Flores-Neder J. Sleep disordered breathing and daytime quality of life in children with allergic rhinitis during treatment with intranasal budesonide. Ann Allergy Asthma Immunol. 2004;92:240 –244 10. Klassen AF, Lee SK, Raina P, Chan HW, Matthew D, Brabyn D. Health status and health-related quality of life in a population-based sample of neonatal intensive care unit graduates. Pediatrics. 2004;113:594 – 600 11. Warschburger P, Buchholz HT, Petermann F. Psychological adjustment in parents of young children with atopic dermatitis: which factors predict parental quality of life? Br J Dermatol. 2004;150:304 –311 12. World Health Organization Pneumonia Vaccine Trial Investigators’ Group. Standardization of Interpretation of Chest Radiographs for the Diagnosis of Pneumonia in Children. Geneva, Switzerland: Department of Vaccines and Biologicals, World Health Organization; 2001. Available at: www.who.int/vaccine㛭research/documents/en/pneumonia. children.pdf. Accessed February 21, 2005 13. Juven T, Mertsola J, Toikka P, Virkki R, Leinonen M, Ruuskanen O. Clinical profile of serologically diagnosed pneumococcal pneumonia. Pediatr Infect Dis J. 2001;20:1028 –1033 14. Moustaki M, Zeis PM, Katsikari M, et al. Mesenteric lymphadenopathy as a cause of abdominal pain in children with lobar or segmental pneumonia. Pediatr Pulmonol. 2003;35:269 –273 15. Klein J. Bacterial pneumonias. In: Feigin R, Cherry J, Demmler G, Kaplan S, eds. Textbook of Pediatric Infectious Diseases. 5th ed. Philadelphia, PA: W. B. Saunders; 2004:299 –310 16. Miedema CJ, Kors AW, Tjon ATWE, Kimpen JL. Medical consumption and socioeconomic effects of infection with respiratory syncytial virus in the Netherlands. Pediatr Infect Dis J. 2001;20:160 –163 17. Nurmi T, Salminen E, Ponka A. Infections and other illnesses of children in day-care centers in Helsinki. II: The economic losses. Infection. 1991;19:331–335 18. Central Bureau of Statistics (Israel). Statistical abstract of Israel no. 53, Table 5.28. 2002. Available at: www.cbs.gov.il/shnaton53/ shnatone53.htm. Accessed February 21, 2005 19. Central Bureau of Statistics (Israel). Statistical abstract of Israel no. 54, Table 5.29. 2003. Available at: www.cbs.gov.il/shnaton54/ shnatone54.htm. Accessed February 21, 2005 20. Black SB, Shinefield HR, Ling S, et al. Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than five years of age for prevention of pneumonia. Pediatr Infect Dis J. 2002;21:810 – 815 21. Whitney CG, Farley MM, Hadler J, et al. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med. 2003;348:1737–1746 22. Lieu TA, Ray GT, Black SB, et al. Projected cost-effectiveness of pneumococcal conjugate vaccination of healthy infants and young children. JAMA. 2000;283:1460 –1468 23. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 1997; 46(RR-8):1–24 24. Weycker D, Richardson E, Oster G. Childhood vaccination against pneumococcal otitis media and pneumonia: an analysis of benefits and costs. Am J Manag Care. 2000;6:S526 –S535 25. Ray GT, Butler JC, Black SB, Shinefield HR, Fireman BH, Lieu TA. Observed costs and health care use of children in a randomized controlled trial of pneumococcal conjugate vaccine. Pediatr Infect Dis J. 2002;21:361–365

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Community-Acquired Pneumonia in Children: Quantifying the Burden on Patients and Their Families Including Decrease in Quality of Life Yaron Shoham, Ron Dagan, Noga Givon-Lavi, Zvika Liss, Tomer Shagan, Orly Zamir and David Greenberg Pediatrics 2005;115;1213-1219 DOI: 10.1542/peds.2004-1285 Updated Information & Services

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