title: Respiratory Virus-Associated Severe Acute Respiratory Illness and Viral Clustering in Malawian Children in a Setting With a High Prevalence of HIV Infection, Malaria, and Malnutrition.
abstract: BACKGROUND
  We used data from 4 years of pediatric severe acute respiratory illness (SARI) sentinel surveillance in Blantyre, Malawi, to identify factors associated with clinical severity and coviral clustering.
  
  
  METHODS
  From January 2011 to December 2014, 2363 children aged 3 months to 14 years presenting to the hospital with SARI were enrolled. Nasopharyngeal aspirates were tested for influenza virus and other respiratory viruses. We assessed risk factors for clinical severity and conducted clustering analysis to identify viral clusters in children with viral codetection.
  
  
  RESULTS
  Hospital-attended influenza virus-positive SARI incidence was 2.0 cases per 10 000 children annually; it was highest among children aged <1 year (6.3 cases per 10 000), and human immunodeficiency virus (HIV)-infected children aged 5-9 years (6.0 cases per 10 000). A total of 605 SARI cases (26.8%) had warning signs, which were positively associated with HIV infection (adjusted risk ratio [aRR], 2.4; 95% confidence interval [CI], 1.4-3.9), respiratory syncytial virus infection (aRR, 1.9; 95% CI, 1.3-3.0) and rainy season (aRR, 2.4; 95% CI, 1.6-3.8). We identified 6 coviral clusters; 1 cluster was associated with SARI with warning signs.
  
  
  CONCLUSIONS
  Influenza vaccination may benefit young children and HIV-infected children in this setting. Viral clustering may be associated with SARI severity; its assessment should be included in routine SARI surveillance.
authors.affiliation: Malawi-Liverpool-Wellcome Trust.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Peterson
authors.affiliation: Institute of Infection and Global Health.
authors.forename: Naor
authors.initials: N
authors.lastname: Bar-Zeev
authors.affiliation: Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: Neil
authors.initials: N
authors.lastname: Kennedy
authors.affiliation: Institute of Ageing and Chronic Disease, Faculty of Health and Life Sciences, University of Liverpool.
authors.forename: Antonia
authors.initials: A
authors.lastname: Ho
authors.affiliation: Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: Laura
authors.initials: L
authors.lastname: Newberry
authors.affiliation: World Bank, Hanoi, Vietnam.
authors.forename: Miguel A
authors.initials: MA
authors.lastname: SanJoaquin
authors.affiliation: Malawi-Liverpool-Wellcome Trust.
authors.forename: Mavis
authors.initials: M
authors.lastname: Menyere
authors.affiliation: Malawi-Liverpool-Wellcome Trust.
authors.forename: Maaike
authors.initials: M
authors.lastname: Alaerts
authors.affiliation: Malawi-Liverpool-Wellcome Trust.
authors.forename: Gugulethu
authors.initials: G
authors.lastname: Mapurisa
authors.affiliation: Malawi-Liverpool-Wellcome Trust.
authors.forename: Moses
authors.initials: M
authors.lastname: Chilombe
authors.affiliation: Malawi-Liverpool-Wellcome Trust.
authors.forename: Ivan
authors.initials: I
authors.lastname: Mambule
authors.affiliation: Liverpool School of Tropical Medicine.
authors.forename: David G
authors.initials: DG
authors.lastname: Lalloo
authors.affiliation: Medical Research Council-Gambia, Banjul.
authors.forename: Suzanne T
authors.initials: ST
authors.lastname: Anderson
authors.affiliation: Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi.
authors.forename: Thembi
authors.initials: T
authors.lastname: Katangwe
authors.affiliation: Institute of Infection and Global Health.
authors.forename: Nigel
authors.initials: N
authors.lastname: Cunliffe
authors.affiliation: Malawi-Liverpool-Wellcome Trust.
authors.forename: Nico
authors.initials: N
authors.lastname: Nagelkerke
authors.affiliation: Influenza Division, Centers for Disease Control and Prevention (CDC)-South Africa, Johannesburg.
authors.forename: Meredith
authors.initials: M
authors.lastname: McMorrow
authors.affiliation: Influenza Division, CDC, Atlanta, Georgia.
authors.forename: Marc-Allain
authors.initials: MA
authors.lastname: Widdowson
authors.affiliation: Institute of Infection and Global Health.
authors.forename: Neil
authors.initials: N
authors.lastname: French
authors.affiliation: Institute of Infection and Global Health.
authors.forename: Dean
authors.initials: D
authors.lastname: Everett
authors.affiliation: Division of Infection and Immunity, University College London, United Kingdom.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Heyderman
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008295:Malawi / Q000453:epidemiology; D008297:Male; D009305:Nasopharynx / Q000821:virology; D012141:Respiratory Tract Infections / Q000453:epidemiology*; D014777:Virus Diseases / Q000453:epidemiology*; D014780:Viruses / Q000145:classification* / Q000302:isolation & purification*
keywords: Africa; SARI; children; influenza; viral coinfection